Medical History Form

Completing this form is mandatory. The form must be completed by a parent/guardian and a licensed
medical practitioner (if required).

STUDENT INFORMATION

STUDENT NAME......................................................................................................................................................................................

HOME PHONE......................................................................... DATE OFBIRTH..................................... SEX...................................

PARENT/GUARDIAN NAME(S)...........................................................................................................................................................

MEDICAL EMERGENCY CONTACT INFORMATION

Primary Parent/Guardian Contact Backup Contact

(If parent/guardian listed to the left is unavailable, list the
person who would be authorised to make medical
decisions for the student.)

Name........................................................................................ Name.............................................................................................

Relation with Student......................................................... Relation with Student..............................................................

Home Phone.......................................................................... Home Phone...............................................................................

Cell Phone............................................................................... Cell Phone....................................................................................

MEDICAL EMERGENCY INFORMATION

Has any health/medical insurance cover been put in place for the student attending the programme?
YES NO
Please be advised that neither YTS Program, nor Pathways World School, Aravali are liable to cover any
costs incurred due to medical visits to doctor(s)/hospital(s), medications, x-rays etc.
We shall only bear the upfront payment of the initial costs of any treatment(s), and the parent/guardian of
the above student shall be liable to reimburse YTS Program for all expenses we bear for the student.
Please upload a copy of your health insurance policy card along with this form.
 Medical History Form

STUDENT FIRST NAME.......................................................... STUDENT LAST NAME...........................................................

MEDICAL CONDITIONS

1)History of Medical conditions: Please check if your child is under treatment for/deals with any of the following:

Asthma ......................................................................................................................................................... Yes No

Frequent Headaches .............................................................................................................................. Yes No

Physical Restrictions ............................................................................................................................... Yes No

Diabetes ....................................................................................................................................................... Yes No

Fainting ........................................................................................................................................................ Yes No

Seizures ........................................................................................................................................................ Yes No

(If yes, please mention date of the last seizure)

Serious Eye Condition ........................................................................................................................... Yes No

Hearing Impairment ............................................................................................................................... Yes No

Surgery ........................................................................................................................................................ Yes No

Other Ailments ......................................................................................................................................... Yes No

(If yes, please explain in detail)...................................................................................................................................................................
............................................................................................................................................................................................................................

2) Has your child received any psychological or emotional counselling? Yes No

(If yes, please explain in detail)...................................................................................................................................................................
............................................................................................................................................................................................................................

3) Is your child allergic to anything (medication, food, insect bites etc.? Yes No
Is the allergy life threatening? ............................................................................................................. Yes No
Please specify the allergy........................................................................................................................................................................
What are the symptoms of the allergic reaction?.........................................................................................................................
 Medical History Form

STUDENT FIRST NAME.......................................................... STUDENT LAST NAME...........................................................

What is the treatment for the allergic reaction?.........................................................................................................................

What should we tell the doctor?.......................................................................................................................................................

........................................................................................................................................................................................................................

What medication can be used to treat a sudden allergic reaction? ..................................................................................

Is your child carrying this medication with them?.................................................................... Yes No

MEDICAL SPECIAL NEEDS

No Special Requirements

Physical Disability (short term, such as recovering from surgery, injury, etc.)
(If yes, please mention date of the last seizure.......................................................................................................................................

Physical Disability (long term)

(If checked, please specify the details).......................................................................................................................................................

Other
(If checked, please specify the details).......................................................................................................................................................

DIETARY SPECIAL NEEDS

No Special Requirements

Diet Related Allergies

(If checked, please specify the details).......................................................................................................................................................

Other Dietary Needs or Restrictions

(If checked, please specify the details).......................................................................................................................................................
 Medical History Form

STUDENT FIRST NAME.......................................................... STUDENT LAST NAME...........................................................

MEDICAL POLICIES
YTS Summer Program staff will not prescribe, dispense or administer any medication. Participants under
medication need to be able to administer medications on their own.

Parents/Guardians must ensure that their child is aware of her/his own medication schedule.
YTS Summer Program staff will not oversee participants’ adherence to medication schedules.

Please consult medication advisors regarding continuation of medication during the course of the
programme. (Note: We have observed in previous programmes that some participants choose to avoid
taking their medication) during the programme, which impacts the participant’s social as well as academic
adjustment to the programme. We threrefore advise parents to consult their medical practitoner on the
continuation od their child’s medication during the course of the programme.

NON-PRESCRIPTION MEDICATION

Please provide a complete list of all non-prescription medications your child will be bringing along or
might need to purchase during the programme.

Staff at the programme will have limited supply of medication such as Acetaminophen (e.g. Paracetamol,
Crocin), Ibuprofen (e.g. Combiflam), Lomotil for diarrhoea etc. However, parent/guardian consent is
required before any participant is allowed to take them. Participants needing constant medication are
requested to bring enough supplies that can last them for the entire duration of the programme.

PARENT CONSENT

I give consent to the YTS Summer Program staff to allow my child to self-administer (in their presence) the
medications mentioned below which will be purchased/stored at the programme. I hereby, release the YTS
Summer Program, its employees and agents, from any liability that might result from my child’s intake of
the non-prescription medication.

(Please check all that apply to your child)

Acetaminophen (e.g. Paracetamol, Crocin) Diominic DCA for common cold

Lomotil for Diarrhoea Ibuprofen (e.g. Combiflam) Domstral for Nausea

Name of Parent/Guardian...................................................................................................................................................................

Signature of Parent/Guardian..................................................................... Date....................................................................

 Medical History Form

STUDENT FIRST NAME.......................................................... STUDENT LAST NAME...........................................................

MEDICAL TREATMENT AND MEDICATION CONSENT

(To be filled by PARENT/GUARDIAN)

Please read carefully and sign. Your signature indicates that you fully understand and agree to the
authorisations and acknowledgements of your responsibilities and waiver of liabilities

I grant my authorisation and consent to the YTS Summer Program to seek emergency diagnostic/medical
treatment or care as required by my child. I understand the YTS Summer Program will contact me prior to
such treatment or care, in case of unforeseen circumstances, I understand the YTS Summer Program will
notify me as soon as possible of any diagnosis or treatment provided.

I am aware of and understand the risks associated with such treatments, including (but not limited to)
serious physical injury and it is also understood that the YTS Summer Program is not responsible or liable
for any treatment provided.

It is also understood that the YTS Summer Program is not responsible for filling any insurance claims or
making payments for the emergency diagnosis and treatment. I accept full responsibility for payment of
any and every invoice or bill for treatment or care provided to my child. I authorise the healthcare facility
(if any) that tenders said treatment or care to release the medical information required for payments of
related insurance claims.

I hereby release the YTS Summer Program and its directors, agents and employees from all expenses or
liabilities resulting from:

- Any emergency medical treatment or care provided to my child, and/or,

- My child failing to adhere to her/his medical schedule.

Signature of Parent/Guardian............................................... Print Full Name...........................................................................

Signature of Parent/Guardian............................................... Authority (if Guardian).............................................................

 Medical History Form

STUDENT FIRST NAME.......................................................... STUDENT LAST NAME...........................................................

PRESCRIPTION MEDICATIONS
MUST BE FILLED by a Medical Practitioner (If your child is taking prescription medication)
• Medical Practitioner must list all medications prescribed to the participant, including dosage and
schedule.
• Participant must carry original bottles labelled with their name, contents and dosage information.
In case of pre-packed pill organisers, the participants must carry corresponding pill bottles
dispensed by pharmacy labelled with name, contents and dosage information.

Medication................................................ Dosage.................................................. ........ Time ................A.M..................P.M

Participant will take medication from dates (dd/mm/yyyy)...........................................to ................A.M..................P.M

Medication................................................ Dosage.................................................. ........ Time ................A.M..................P.M

Participant will take medication from dates (dd/mm/yyyy)...........................................to ................A.M..................P.M

Medication................................................ Dosage.................................................. ........ Time ................A.M..................P.M

Participant will take medication from dates (dd/mm/yyyy)...........................................to ................A.M..................P.M

Medication................................................ Dosage.................................................. ........ Time ................A.M..................P.M

Participant will take medication from dates (dd/mm/yyyy)...........................................to ................A.M..................P.M

Important information (side effects, toxic reactions, drug interactions, omission reactions, potential
problems resulting from physical injury).......................................................................................................................................
Contraindications for medication administration: ....................................................................................................................
Parents must ensure that all medication their child is carrying has been labelled by the pharmacist with the
following information:
1. Child Name 2. Dosage Prescribed
3. Medication Dispensed 4. Time at which medication must be taken

Medical Practitioner Name..................................................................................................................................................................

Medical Practitioner Signature.................................................................... Date .........................................................................