Medical Form Part C – Miami March of the Living

March of the Living 2024-2025 Application

Medical Form Part C: Medication and Mental Health

To be completed by Parent(s)/Guardian(s)

Physical Examination Form Upload due by

October 1, 2024.

Medical Form Part B & C due by

October 1, 2024.

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Please note that it is extremely important that you provide us with complete information about your teen's medical and psychological history. This information is vital to ensure your teen's safety and well-being. Please take the time to complete this form accurately and thoroughly. Omissions can be serious for the individual and can affect the entire group.

All information will be kept strictly confidential by Miami's March of the Living staff and will only be referenced or shared with others to assist in ensuring the physical, psychological, and emotional well-being of your teen.

Please complete all fields to the best of your ability.

*Denotes a required field

MEDICATIONS

Please note: Participants who take medication on a regular basis will be responsible for that regimen during all travel and meeting times. The medical professional with the group during Miami's Leo Martin March of the Living is not responsible for dispensing medication on a regular basis. March staff members, other than a licensed medical professional, are not permitted to dispense medication of any kind; therefore, the participant must bring and be responsible for all of their own medication. If the participant requires medical attention beyond their regular routines they will see a licensed medical professional.

Is your teen currently taking medication(s) and/or has the applicant taken medication(s) in the past year?^*

Please list any medications taken during the school year that teen will take during the trip. Please note, that it is imperative that participants remain on their medications during the trip, as we follow a rigorous schedule, both academically and emotionally. If none, please write "none":^*

Do any of these medications need to be refrigerated? Please note: If any of these medications need to be refrigerated, please contact our office. We are unable to accommodate any medications that require refrigeration.^*

Medications to be taken while traveling overseas. If none, please write "none":^*

HEALTH INFORMATION CONFIRMATION AGREEMENT^*

The health information presented here is correct to the best of my knowledge, and my child has permission to engage in all program activities except as noted by me.
 
By signing below I agree to inform and advise Miami's Leo Martin March of the Living program personnel of any change in my child’s medical, psychological, or emotional health until the end of the program.
 
I hereby give permission to the health professional selected by the program staff to order x-rays, routine tests and treatment for the health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the program staff to hospitalize, secure treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above.
 
I hereby give permission to the health professtional selected by the program staff to administer over-the-counter medication (if needed).
 
I hereby consent to allow Miami's Leo Martin March of the Living Program staff to contact the below named physician and/or nurse practitioner to obtain information about my teen, that is relevant to providing appropriate levels of care throughout the program and specifically during the trip.

I agree

Name of Health Care Professional^*

Health Care Professional Phone^*

Print PARENT/GUARDIAN name to designate electronic signature.^*

MENTAL HEALTH INFORMATION

Are there any medical, psychological, or emotional conditions that could affect your teen's participation in Miami's Leo Martin March of the Living Program or about which you believe we should know to best support them during this program?^*

Please describe any relevant issues of concern.^*

Are there any restrictions, prohibitions, or special instructions regarding participating in Miami's Leo Martin March of the Living programming and activities?^*

Please describe any relevant issues of concern^*

Does your teen demonstrate any learning, behavioral, attention, or anxiety issues?^*

Please describe any relevant issues of concern.^*

Has your teen had a significant life event (e.g. close family death, divorce, recent move) that continues to affect his or her life?^*

Please describe any relevant issues of concern^*

If your teen is exhibiting problematic behavior, how do you address the situation with them so that they respond well to you?^*

Is your teen under the care of a psychiatrist, psychologist and/or social worker?^*

Please confirm that you fully understand that if your teen is under the care of a Mental Health Professional, it is your responsibility to complete the form below from the Mental Health Professional to be submitted to which includes the above information regarding their care and treatment by acceptance into the program.^*

Yes. I understand.

You MUST send this form and send it to your teen’s mental health provider if they are in the care of a mental health provided and they need to completed by December 1st

Mental Health Care Name^*

Mental Health Care Phone^*

Mental Health Care Email^*

IMPORTANT NOTE: If your teen is on medication for emotional health issues, it is recommended that s/he be on the same medication/dosage for at least 1 month prior to and during the trip. Please provide additional information and notify us if there is any change.

Admin use only (do not edit)

Registrant(Teen) Email Address^*

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