Health Statement

(This form is to be filled in by JAG Nevada parents/guardian and Specialist)

Please print in blue or black ink

Name_______________________________________________________ Birthdate______________________ Sex__________

High School__________________________________________________ JAG Specialist____________________________________________

Parent/Guardian (or spouse)__________________________________________________ Relationship___________________________________

Home Address______________________________________________________________________________ Phone_______________________

Street & Number City State Zip

Second Parent/Guardian or Emergency Contact_________________________________________ Relationship_____________________________

**Optional. This information is needed when a child is seen for emergency treatment. By providing this now, it can save time in an emergency. The JAG Specialist
keeps these records confidential.

EMERGENCY INFORMATION

Family Physician_____________________________________________________________ Phone______________________________

Who is responsible for medical payments? Insurance Individual
IF INSURED, Medical Insurance Company Name__________________________________________ Phone______________________________
Name of Primary Insured______________________________________________ Group Number_______________________________________
Note: Insurance coverage is not required for participation.

BRIEF MEDICAL HISTORY

Special Health Concerns___________________________________________________________________________________________________

Asthma Yes No Heart Problem Yes No

Diabetes Yes No Allergies Yes No
Seizures Yes No Other
(Include pregnancy, recent surgery, or other chronic condition)

Current Medications:
Medication Dosage per day
_______________________________________________________ __________________________
_______________________________________________________ __________________________
_______________________________________________________ __________________________

Note: If your child is taking medication regularly, please provide a supply in a labeled container.
(Please Note: Prescription medication requires a current prescription label. Over-the-counter medication must be accompanied by an order from a licensed health
care provider.)
Should activity be restricted? Yes No If yes, please explain_____________________________________________________

Authorization for Treatment:

The information given above is correct to my knowledge. I understand first-aide will be available at the event; JAG Nevada students will be
supervised and if a serious illness or injury develops, medical and/or hospital care will be given. I further understand in case of serious injury or
illness we will be notified, but if it is impossible to contact us, we give permission for emergency treatment or surgery as recommended by the
attending physician. I understand that I will be financially responsible for medical treatment. I further agree to hold Jobs for Nevadas Graduates,
Inc., its employees, and agents harmless for any injury or illness.

Signature of parent/guardian_______________________________________________________ Date________________________

**IMPORTANT**
This must be completed for participation and attendance at any JAG Nevada sponsored event, including the Leadership Development
Conference, Career Development Conference, or JAG Nevada Legislative Day.

Rev. 06/2017