Youth Information Form

Must be completed for any youth who will participate in any of our programs.
  = Required

Contact Information

Youth Information

            

  / /                

   

       


Parent/Guardian 1

   

      

 

Parent/Guardian 2 

   

     

Emergency Contact (Local)

   

     

Emergency Contact (Out of State)

   

   

Health Information

Medical History

Has your child ever had any of the following injuries, conditions or illnesses?

    Asthma
    Ear Infections
    Seizure Disorder
    Developmental Disorders
    GI Disorders
    Heart Problems
    Diabetes
    Psychiatric Diagnosis
    ADD/ADHD
    Muscular/Skeletal Injury
    Other

Please describe information about any of items above that you answered "yes" to; any significant medical history; any hospitalization, doctor visits or surgical history of consequence in the past 5 years; and any other health related information or further suggestions for Mountaineers personnel

 


Allergies

Please list all known allergies

Allergy 
Usual Reaction 
Treatment   

Allergy 
Usual Reaction 
Treatment   

Allergy 
Usual Reaction 
Treatment   

Allergy 
Usual Reaction 
Treatment   


Immunizations

Please list the date of the most recent immunization or booster for those listed below. While this is not required to complete the form, it is helpful information to provide medical personnel in the event of an injury or illness.  (alternatively, upload a copy of your child's immunization records)

 

Chickenpox
     
Diphtheria
     
Hepatitis B
     
Measles
     
Mumps
Rubella
Pertussis
Polio
Tetanus
HIB
PCP
Negative TB Test

Has the youth ever tested positive for Tuberculosis?     

If so, when?   

Insurance Information

It is the responsibility of every parent or legal guardian to provide the participant's accident and health coverage while participating in Mountaineers activities.  The Mountaineers does not provide any accident or health coverage for its participants.

Is the participant covered by medical/hospital insurance?     

 

 

      

      

     

      

Authorization for Treatment

This health history is correct to the extent of my knowledge, and my child has permission to engage in all prescribed activities.  I hereby give permission to the First Aid or medical personnel selected by a Mountaineers Leader to provide treatment according to their assessment of my child’s needs.  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by a Mountaineers Leader to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above.  I understand that The Mountaineers does not provide emergency transportation and I authorize transportation by ambulance according to the judgment of the staff.  I understand the program fees do not include health and accident insurance and I will be responsible for any and all charges incurred in obtaining prompt medical attention.  This completed form may be printed for trips off of the Mountaineers property.

Parent/Guardian Initials       Date     

Notes
 


OTC Medication Administration Authorization

As part of the Mountaineers programs, youth may spend 2-10 days in the care of Mountaineers Staff and Volunteers, away from parents.  While we promote a healthy environment by ensuring youth are fed and hydrated, and by avoiding extreme conditions when possible, there are times when a youth’s comfort and ability to fully participate can be significantly improved with over-the-counter (OTC) medication.  Examples include headaches, nausea, allergies, minor injuries and menstrual cramps.

I give permission for the Mountaineers staff and volunteers to administer sunscreen, hand sanitizer and/or over-the-counter medications to my child as needed at their discretion.  The Mountaineers staff and volunteers will never administer a dosage that is greater than the dosage recommended on the medication directions for use.  I assert that my child has no known allergies to any brands of these products, and acknowledge that allergies can develop at any time. 

I hereby give representatives of The Mountaineers permission to administer to my child any brand of any of the following non-prescription over-the-counter medications:

    Sunscreen
    Hand Sanitizer
    Ibuprofen
    Acetaminophen
    Diphenhydramine HCl (antihistamine found in brands like Benadryl)
    Antacid or Anti-diarrheal (like Tums or Pepto Bismol)
    Topical Antihistamine
    Topical Antibiotic
    Cold or Allergy Medication

Notes
 


Prescription Medication

All prescription medications must be in their original bottle, labeled with the child's first and last name, and must be current (not expired).  All controlled medication and medication requiring hypodermic needle administration (with the exception of Epipens which may be carried by the youth) must be kept in a zip lock bag or other container with accompanying doctor's orders, and must be stored with Mountaineers Staff or designated volunteer leaders.

Youth may carry non-controlled "as needed" (PRN) prescription medications such as Epipens and Albuterol inhalers with parent permission.  

Click on the arrow next to each section to add a medication.

Prescription Medication 1

Name of Medication     Controlled drug?  

Will the youth carry the medication and self-administer?  

Dose     

Method (eg. oral, topical, injection)      

Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner)   

If PRN (as needed), describe when this medication should be taken  

Relevant side effects of medication   

Plan for management of side effects   

What happens if this medication is NOT taken?   

Prescription Medication 2

Name of Medication     Controlled drug?  

Will the youth carry the medication and self-administer?  

Dose     

Method (eg. oral, topical, injection)      

Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner)    

If PRN (as needed), describe when this medication should be taken  

Relevant side effects of medication   

Plan for management of side effects   

What happens if this medication is NOT taken?  

Prescription Medication 3

Name of Medication     Controlled drug?  

Will the youth carry the medication and self-administer?  

Dose     

Method (eg. oral, topical, injection)     

Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner)    

If PRN (as needed), describe when this medication should be taken  

Relevant side effects of medication   

Plan for management of side effects   

What happens if this medication is NOT taken?   

Prescription Medication 4

Name of Medication     Controlled drug?  

Will the youth carry the medication and self-administer?  

Dose     

Method (eg. oral, topical, injection)     

Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner)    

If PRN (as needed), describe when this medication should be taken  

Relevant side effects of medication   

Plan for management of side effects   

What happens if this medication is NOT taken?   

Prescription Medication 5

Name of Medication     Controlled drug?  

Will the youth carry the medication and self-administer?  

Dose     

Method (eg. oral, topical, injection)       

Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner)    

If PRN (as needed), describe when this medication should be taken  

Relevant side effects of medication   

Plan for management of side effects   

What happens if this medication is NOT taken?   

Prescription Medication 6

Name of Medication     Controlled drug?  

Will the youth carry the medication and self-administer?  

Dose     

Method (eg. oral, topical, injection)      

Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner)    

If PRN (as needed), describe when this medication should be taken  

Relevant side effects of medication   

Plan for management of side effects   

What happens if this medication is NOT taken?   

 


Over the Counter Medication Permission

In addition to over-the-counter (OTC) medication that Mountaineers leaders may carry (see OTC Medication Authorization section above), parents may send OTC Medication with their children to Mountaineers programs but must list them here. All medications, including OTC Medications must be in their original bottle, labeled with the child's first and last name, and must be current (not expired). Mountaineers leaders will distribute parent-indicated dosage or recommended dosage on label, whichever is less. Children aged 14+ may carry their own OTC medication and self-administer with parent permission.  Any medications not listed on this form will be confiscated and returned to the parents/guardians.

Click on the arrow next to each section to add an over-the-counter medication.

OTC Medication 1

Name of Medication   

If the youth is aged 14+, will they carry the medication and self-administer?  

Dose   

Describe when this medication should be taken  

OTC Medication 2

Name of Medication   

If the youth is aged 14+, will they carry the medication and self-administer?  

Dose   

Describe when this medication should be taken  

OTC Medication 3

Name of Medication   

If the youth is aged 14+, will they carry the medication and self-administer?  

Dose   

Describe when this medication should be taken  

OTC Medication 4

Name of Medication   

If the youth is aged 14+, will they carry the medication and self-administer?  

Dose   

Describe when this medication should be taken  

OTC Medication 5

Name of Medication   

If the youth is aged 14+, will they carry the medication and self-administer?  

Dose   

Describe when this medication should be taken  

OTC Medication 6

Name of Medication   

If the youth is aged 14+, will they carry the medication and self-administer?  

Dose   

Describe when this medication should be taken  

 

Special Circumstances

The Mountaineers strives to be a welcoming and inclusive organization.  We believe that our program participants benefit from sharing meaningful experiences in a positive outdoor environment with others who bring a diversity of skills, life experiences, personalities, perspectives and beliefs to the program.

Many youth have life situations that may influence their experience in Mountaineers programming.  These situations may be medical, physical, dietary, religious, emotional, family-related, school-related or trauma-related.  In order to best serve each youth, we request that parents/guardians share this information with us on this form.

The Mountaineers is an Outdoor Education organization, and we strive to provide the best possible learning environment so that participants have the best chance of success in skill– and community-building.  This includes maintaining physical and emotional comfort and safety for participants.  The Mountaineers will make every effort to accommodate any special requests associated with the circumstances listed on this form.  In the event that we cannot make accommodations, we will communicate that in advance with the family, and the youth will have the option to participate without accommodation or to forego participation.

The Mountaineers takes privacy and confidentiality seriously.  Information on this form will be shared ONLY with the individuals listed as “primary leaders” for the activity or activities in which the youth is participating.  Information will not be disclosed to any other individuals except as necessary for the safety of the youth and as communicated with the youth and family in advance of disclosure.  Youth may have the option to forego participation in lieu of disclosure.


Does the youth participant have any special dietary needs?   
 

Does the youth participant receive any special services at school?   

Please describe anything we can do to help your child be successful in our programs.
 

Does the youth participant take any regular medication during the school year?  
 

Are there any recent adjustments or family situations that may be impacting the youth participant? 
 

Are there any religious accommodations you would like us to make for the youth participant?
 
 

In the event of injury or illness, The Mountaineers leaders will provide basic first aid in the field according to their training and certification level, and if needed will transport the youth by ambulance to the nearest definitive care facility.  Do you have any specific instructions regarding medical care for the youth participant?   
 

Does the youth have any short-term or long-term physical limitations?  
 

Are there any specific accommodations you would like to request that have not already been listed on this form?  
 

Is there anything else you would like us to know?  
 

Confidentiality

By answering "no" to the following questions, you are requesting that Mountaineers representatives consult with the family and youth before disclosure.

May we disclose Special Circumstances information at our discretion to other adult volunteers and staff in the program?     

May we disclose Special Circumstances information at our discretion to other youth in the program?     

Notes
 


Disaster Preparedness

We live in an area where earthquakes, volcano eruptions or tsunamis can occur.  While we all hope to be in safe locations when these events happen, we want to be prepared to care for your child should these or other natural disasters happen while your child is in program.  Our staff are prepared to care for youth in our programs for an extended period of time should a disaster event make it difficult or impossible for parents to reconnect with their children.  Please provide the information below to help us care for your child should this type of event occur.

Does the youth participant have any medical conditions we need to know about for long term care that may not be listed in their program forms?   
 

Does the youth participant take any medication at home?  

Please describe the medication(s) and what to expect if the child cannot take the medication(s)
 


Attachments

attach documents needed per your program's requirements.  check with your program leader if you're unsure which documents are needed.

Most file types are supported, including .pdf and .jpg files, allowing you to scan a document or upload an image from your phone or other device.

Copy of Insurance Card (while not required, this can help expedite things in the event of an emergency and ensure your insurance covers any costs):   

Parent Driver's License (required for parents volunteering to drive):  

Second Parent Driver's License   

Parent Driver History (required for parents volunteering to drive):   

Second Parent Driver History   

Driver histories can be purchased for $13 at the Washington State Department of Licensing. Select "volunteer" when asked for the type of record.  The cost is reimbursable by The Mountaineers through the program leader.