UMass Boston Youth Program Participant Medical Forms 2024

Name of Participant:
Parent/Guardian:
Address:
Phone:
Name of Medical Provider
Address:
Phone:

Youth Program Medical Requirements

*All documentation must include your child's name and birthdate*

1. Application

All forms must be signed by parents/guardian.

1. Consent to Treat Minor Patients, signed by parents/guardian (page 4)
2. Health History (page 5)
3. Authorization, Waiver and Consent for OTC Medication (page 7)

2. Immunization records

Submit one of the following:

1. Certificate of Immunization (page 6) OR
2. Immunization Form from medical provider or school record (this is usually given to you at a yearly physical to give to the school nurse)

3. Required Vaccines

The following vaccines are required. If you need a Religious or Medical Exemption for any required vaccine(s), please submit a letter from the medical provider.

1. Td (Td, Tdap, Dtap)
2. MMR: Two (2) doses
3. Varicella: Two (2) doses
   *If child had the Chickenpox (varicella), they may not have received a full Varicella series (may have 1 or none). If that is the case, you can submit documentation from your child's medical provider stating they had chickenpox.
4. Hep B: Three (3) doses
5. Polio: Three (3) or Four (4) doses, depending on type given
6. Meningococcal (MCV4) REQUIRED ONLY FOR OVERNIGHT PROGRAMS

4. Physical exam

1. Must include wording to the effect of "student is cleared for full participation in school and sports without restriction" **signed by medical provider. (**Medical Provider refers to the child's Pediatrician, aka "PCP" which may be a Doctor (MD, DO), Nurse Practitioner (NP), or a Physician Assistant (PA)).
2. Must be dated within the last 18 months

THESE SECTIONS ARE ONLY REQUIRED IF APPLICABLE TO THE PARTICIPANT

5. Medications

If your child will be taking any medications while at their program, Prescription or Over the Counter (OTC), you must submit orders from medical provider. The medications must be sent to the program in their original packaging with your child's name on them.

1. If child needs medication that the nurse will store and administer submit: "Authorization for Administration of Medication" form (page 8)
2. If child needs medication and can take it by themselves: submit: "Authorization to Self-Administer Medication" form (page 9)

6. Anaphylactic Allergy

If your child has an anaphylactic allergy:

1. Submit an Anaphylactic Action Plan from your child's medical provider which should include if the student can self-carry and self-administer their epi pen.
2. Send child to program daily with Epinephrine Auto Injectors (aka EpiPens) which should always be kept in pairs of two (2) and in the original packaging from the pharmacy with the prescription attached.

7. Asthma

If your child has asthma:

1. Submit an "Asthma Action Plan," from your child's medical provider which should specify if the student may self-carry and self-administer the medications.

8. Diabetes

If your child has diabetes:

1. Submit a "Diabetes Care Plan" from their medical provider. UHS staff will have a meeting (can be a phone call) with parent/guardian before the start of the program to review care plan and create an individualized program care plan for the student.
2. Plan to send your child every day to their program with all of their necessary diabetes supplies as we do not have these supplies to give them.

9. Other chronic medical conditions

If your child has any other medical problems:

1. Submit action plan, medication orders as appropriate and plan to coordinate with our nursing staff to create an individual care plan for your child while they are at our program.

CONSENT TO TREAT MINOR PATIENTS

Your child has been accepted to a youth program at the University of Massachusetts Boston. University Health Services offers first aid to minors who are participating in university sponsored youth programs. Massachusetts law requires consent of a parent/legal guardian for medical care of minors, including first aid. Please complete the following consent form to allow University Health Services to provide first aid to your child.

I, (print name here), am the parent/legal guardian of (print name of participant), currently a minor, whose date of birth is / / . I authorize the University of Massachusetts Boston Health Services to provide first aid to the youth.

I understand that, should my minor participant need more extensive medical care I will be notified by a healthcare provider through University Health Services. I also understand that if the injury/illness is determined to be life threatening or require immediate medical attention beyond first aid, that an ambulance will be called to take my child to the hospital and that the provider will make every effort to contact me.

By signing this, I acknowledge that I have read and that I understand this consent, and that any questions that I have prior to signing could be answered by calling University Health Services at (617) 287-5660.

HEALTH HISTORY

AS A YOUTH PARTICIPANT, PARENT OR GUARDIAN I UNDERSTAND THAT: If your child has a pre-existing medical condition, participation in any strenuous activities or recreational time may not be recommended. This information will be kept in strict confidence and will only be shared with your permission. UMass Boston requests the information below so that, in case of emergency, we will have accurate information so that we can provide and/or seek appropriate treatment. You are accountable for providing an accurate medical history. Final determination about whether to participate is the responsibility of UMass Boston's consulting health care provider. If you have any medical issue that is not requested below, but which you think is important, please include that information.

(To be completed by Parent/Guardian)

Has the participant had, or does the participant have, any of the following? Check Yes or No.

	YES	NO		YES	NO
Medication allergies:			Asthma
Food allergies or special diet			Easy Bleeding
Seizures/epilepsy/fainting spells			Emotional/psychiatric/behavioral issues
Diabetes			Sickle cell trait or disease
Concussion or serious head injury			High blood pressure
Heat stroke/exhaustion			Heart disease/ heart defect
Contact lenses/glasses			Any limitations that restrict running, swimming, participating in group recreational activities?

If "Yes" to any above, or there is any additional information on the youth's physical health please provide details here:

Will the youth need to take any medications during program hours?

If yes, please submit the form "Authorization to Administer Medications" (page 8) as well as "Authorization to Self-Administer Medication" (page 9) if applicable.

Is the participant pregnant? (females only)

CERTIFICATE OF IMMUNIZATION

Name:		Date of Birth:		Sex:	Select Female Male Other

Vaccine		Date/Vaccine Type
Hepatitis B (e.g., HepB, HepB-Hib, DTaP-HepB-IPV)		1: 2: 3:
Haemophilus influenzae type b (e.g., Hib, HepB-Hib, DTaP-Hib)		1: 2: 3:
Diphtheria, Tetanus, Pertussis (e.g., DTaP, DT, DTaP-Hib, DTaP-HepB-IPV, Td)		1: 2: 3: 4: 5: 6:
Measles, Mumps, Rubella (MMR)		1: 2:
Varicella (Var)		1: 2:
Hepatitis A (HepA)		1: 2:
Polio (e.g., IPV, DTaP-HepB-IPV)		1: 2: 3: 4:
Pneumococcal Polysaccharide (PPV23)		1: 2:
Pneumococcal Conjugate (PCV7)		1: 2: 3:
Influenza (Inactivated or Live)		1: 2:
COVID 19 (optional) 2 doses (Moderna/Pfizer) OR 1 dose (J&J) + at least one booster		1: 2: 3 (booster):

Serologic Proof of Immunity (If done, fill in below)
Test	Date of Test	Positive	Negative
Measles
Mumps
Rubella
Varicella*
Hepatitis B

* Must also check Chickenpox History box if applicable.

Check the box if this person has a physician-certified reliable history of chickenpox.
Date of chickenpox:

I certify that this immunization information was transferred from the above-named individual's medical records.

Name and Title of Licensed Provider (print):
Date:
Signature of Licensed Provider:
Address:
Phone:

PARENT/GUARDIAN AUTHORIZATION, WAIVER AND CONSENT FOR OVER-THE-COUNTER MEDICATION

Over-the-Counter (OTC) Medication may at times need to be administered. All of the following medications will be administered as necessary unless you indicate below those meds you do not want your child to receive.

I hereby request that the following medications NOT be given to

You may not dispense those checked except in an emergency.

Acetaminophen (Tylenol)	Ibuprofen (advil/motrin)	Antacid
Benadryl/Antihistamine	Triple Antibiotic Ointment	Cough Drops
Calamine Lotion	Hydrocortisone Ointment	Sun Block

I understand that such administration will be done under the supervision of medical personnel. I authorize the administration of over-the-counter medications to my child as indicated above.

AUTHORIZATION TO ADMINISTER MEDICATION

ONLY REQUIRED IF APPLICABLE TO PARTICIPANT

Name of licensed prescriber and title (please print):

Signature of Parent/Guardian: Date:

*For all Prescription and Over the Counter Medications taken on a regular basis*

Please provide separate sheets for each medication.

A.) TO BE COMPLETED BY PARENT OR GUARDIAN:

I request that my child receive the medication as prescribed below by our licensed healthcare provider. The medication is to be furnished by me in the properly labeled original container from the pharmacy. I understand that the Registered Nurse or other designated healthcare supervisor will administer the medication.

B.) TO BE COMPLETED BY THE LICENSED HEALTHCARE PROVIDER:

Please provide separate sheets for each medication.

I request that my patient, as listed below, receive the following medication:

Name of participant: Date of Birth:

Diagnosis:

Name of medication:

Prescribed dosage, frequency, and route of administration:

Time to be taken during program hours: Duration of treatment:

Possible side effects and adverse reactions (if any):

Other recommendations:

Name of licensed prescriber and title (please print):

Name/Title, Office Phone, Street Address, Apt. #, City, State, Zip Code:

Signature of licensed prescriber: Date:

AUTHORIZATION FOR SELF-ADMINISTRATION OF MEDICATION

ONLY REQUIRED IF APPLICABLE TO PARTICIPANT

*For all prescription and over-the-counter medications that will be taken independently by participant*

Please provide separate sheets for each medication.

Participant Name:

Address:

Date of Birth:

Program Name & Location:

This form must be completed fully in order for the student identified above to self-administer prescription medication during the program (including inhalers, insulin, EpiPens).

A separate Authorization for Self-Administration of Prescription Medication must be completed for each medication to be self-administered.

Self-administration of medication requires the written authorizations (below) of a licensed health care professional and the participant's parent or legal guardian.

AUTHORIZATION FROM PRESCRIBER FOR SELF-ADMINISTRATION OF MEDICATION

Medication name:

Dosages:

Condition(s) for which medication is being administered:

Specific directions (e.g., on empty stomach, with water):

Time/frequency of administration:

If PRN, frequency:

If PRN, for what symptom(s):

Relevant side effect(s):

Dates medication shall be administered from:

Special storage requirements:

Is Participant capable of self-administering this medication: Select Yes No

I hereby affirm that the participant has been instructed in the proper self-administration of the above-described medication.

Name/Title, Office Phone, Street Address, Apt. #, City, State, Zip Code:

Signature of licensed prescriber: Date:

Signature of Parent/Guardian: Date: