If coverage is indicated, remaining fields are required, unless labeled optional. If any are not applicable, please type "NONE."

Indicate ALL medication(s) which is/are taken on a regular basis, both prescription and over-the-counter. Participants are required to turn in ALL prescription medication with the exception of rescue medications (such as rescue inhalers, EPI pens, and emergency insulin). Note: Participants should bring an adequate supply of their medication(s) in original containers.

This field is required. If not applicable, enter "NONE." Include the medication name, prescription/over-the-counter, dosage & directions for each medication.

Example: Tylenol3 (prescription), 300mg every 4 hours, as needed for headaches.

It is recommended that you consult with your child's physician before allowing your child to participate in this Program.

For the following, provide response and explain as appropriate

If Participant has any other medical condition or special needs that you think are important for Program staff to know about, including additional requirements for accommodations in the residence hall due to medical conditions, please include that information here.

To the best of my knowledge, my child/participant is capable of participating safely in the Program and any activity restrictions, allergies, medications are listed on this form.

I give permission to Program staff to provide routine first aid care and in the event of serious illness or injury, I give Program staff permission to seek and authorize emergency medical treatment. I hold harmless and agree to indemnify the Program and the University of Michigan from any claims, causes of action, damages and/or liabilities arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses, that may derive from any injuries to my child that may occur during his/her participation in this Program.

I understand and acknowledge that my failure to disclose relevant information may result in harm to Participant and/or others during this Program. By initialing below, I represent that I have provided all materials and important information to the Program pertaining to Participant's medical, mental and physical condition and that it is accurate and complete. I agree to notify the Program of any changes in my mental, physical or medical condition before the Program begins.

In case of emergency, parent or legal guardian will be contacted. If parent or legal guardian cannot be reached, we will contact the following individuals in the order listed.Each person listed should be reachable by telephone and able to make decisions on behalf of your child if a parent and legal guardian cannot be reached. If necessary, an emergency contact should be able to come to the Program site and pick up your child.