Latin Form E – Medical Information Form – Virginia Governor's World Language Academies

2027 Governor's World Language Academy

This form is due no later than [date]. Note: There are [insert number] sections. REMINDER: Please also send a check (NO CASH) for $75 for the student activity fee, payable to Washington and Lee University with the student’s name and designated Academy (Spanish 2027, French 2027, or German 2027, Japanese 2027, Latin 2027) on the memo line mailed to the University at this address: Virginia Governor’s Language Academy Washington and Lee University 204 W Washington St Lexington, VA, 24450

E: Medical Information Form

Please share your medical information with us by filling out this form.

Student Name(Required)

First Last

School(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Telephone Number(Required)

Parent/Guardian 1 Name(Required)

First Last

Parent/Guardian 1 Cell Phone Number(Required)

Parent/Guardian 1 Work Phone Number

Parent Email(Required)

Parent/Guardian 2 Name

First Last

Parent/Guardian 2 Cell Phone Number

Parent/Guardian 2 Work Phone Number

Medication (prescription drugs and over-the-counter medication taken for certain symptoms) is presently being taken(Required)

Yes

If yes, please provide the (1) Name of medication (2) Why taken (3) Dosage/Frequency (4) Telephone number for ALL medications. Include prescription drugs and over-the-counter medicines that might be needed for headaches, cramps, insect bites, hay fever, etc. Please send all medications with the child; they will be kept by the child unless we are notified otherwise. Note that students must be able to self-medicate; staff are prohibited from administering any medications. Where applicable, please include the prescribing physician's telephone number.

Does student have allergies to food, medication, bees, plants, or anything else about which we should be informed?(Required)

Yes

If yes, please describe. (Does the student have an inhaler or epi pen?)

Are there any medical/emotional problems (i.e., asthma, eating disorders, anxiety disorders, mononucleosis, anemia, heart disease, diabetes, depression, etc.) of which we should be aware?(Required)

Yes

If yes, please describe.

When was the student last seriously ill or hospitalized or has he/she had any recent injuries? Please explain.(Required)

Emergency Contact 1 Name(Required)

First Last

Emergency Contact 1 Phone Number(Required)

Emergency Contact 2 Name(Required)

First Last

Emergency Contact 2 Phone Number(Required)

Does student have Accident/Medical Insurance?(Required)

Yes

No (The University will provide short-term camp accident and medical insurance for the duration of the Academy program)

If yes, please state the Name of Accident/Medical Insurance, Certificate # and Policy #

I agree to participate in electronic signatures(Required)

Yes

I give permission for my child to receive medical and emergency care at the Academy and/or at the host institution and/or at a local hospital or other emergency health care facility while s/he is enrolled at the Academy and for a physician or other appropriate medical personnel to treat my child in a manner he/she thinks appropriate, in case of a medical emergency and/or a problem. I understand that the Academy staff members are not allowed to administer medications and permit my son/daughter to self-administer the prescribed and over-the-counter medications listed on following pages of this medical information form. I agree that all medications shall be in original containers. I understand that I am responsible for the payment of all medical and emergency services rendered to my child, including transportation to medical facilities.(Required)

Yes

My child is allergic to the following medications, including over-the-counter medications:(Required)

Please attach: (1) A copy of your insurance card for the health policy (policies) that cover(s) your child. Many health care providers require that the card be presented before care will be provided. (2) An immunization record for your child that includes the date of the last tetanus shot.(Required)

Max. file size: 512 MB.

Parent/Guardian Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Signature(Required)

Date(Required)

Latin Form E – Medical Information Form

Latin Form E Acknowledgement – Medical Information Form

2027 Governor's World Language Academy

E: Medical Information Form