Educational Programs Medical Information Form

The Medical Information Form is kept confidential and used by our program staff (or emergency medical personnel). Every participant must have a completed Medical Information Form submitted four (4) weeks prior to the event.

Completed Medical Information Forms can be faxed to 281-283-7724, emailed as an attachment to globalprograms@spacecenter.org, or mailed to Space Center Houston, 1601 NASA Parkway, Houston, TX 77058 ATTN:

Education - Space Center University.Participant Information PLEASE PRINT NEATLY

Participant First Name Middle Last Name Date of Birth Age Gender

Contact Parent/Guardian #1 Relationship Daytime Phone

Contact Parent/Guardian #2 Relationship Daytime Phone

Participant is allergic to: Food Other Allergies No known allergiesPlease list all allergies below:

Participant does have an Epi-Pen? YES NO *If participant is bringing an Epi-Pen, SCH is required to have a current, signed Physician’s Authorization Form four (4) weeks prior tothe first day of program. SCH cannot administer medication to participants without physician authorization. Participants are required to bring Epi-Pens each day.

Restrictions If your child has a disability, impairment, or condition that requires medication or other accommodations, please inform SCH of your child’s needs below, prior to program, to ensure that SCH is prepared to address your child’s needs. Once a parent/guardian submits a modification request, SCH will consider that request on a case-by-case basis and will attempt to accommodate your child within a reasonable amount of time.

Does your child have a disability, impairment, condition that requires medication, or any other accommodations?

Parent/Guardian Authorization My child has permission to engage in all prescribed program activities except as noted. The information provided on this form is accurate to the best of my knowledge. I have indicated any special health conditions, including activity limitations, or conditions which should be known to the camp staff and medical personnel. I give consent in advance for medical treatment at the closest facility in case of illness or injury.

Signature of Custodial Parent/Guardian Date Relationship to Participant

Male Female

YES NO If yes, please describe below:

9/21/16

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