Medical History Form
This is for our health center for their records,
and per NYS Dept. of Health regulations.
Use one form per student *** Please make a copy for your records *** Complete and return to: Rensselaer
Polytechnic Institute, Academic Outreach Programs – Summer@Rensselaer - 110 8th Street – 1516 PE, Troy,
NY, 12180-3590 USA or email to soaps@rpi.edu
Student Name: _______________________________________________
Program Name: ______________________________________________
I. PERSONAL INFORMATION – Required for all participants under 18 years of age attending a Summer@Rensselaer
residential program. Complete sections I-VII of this form and medication form(s).
**Please make a copy of this form for your records.
Student Name:
Date of Birth:
Age:____________
Sex (M/F) ______
Parent Email Address: _____________________________________
Home Mailing Address:_________________________________________________________________________________
City: ___________________________________________________ State: ____________________
Zip: ____________
Emergency Information
Parent/Guardian with legal custody to be contacted in case of illness or injury:
Name : _______________________________ Relationship to participant: __________________________________
Home Phone: ______________________
Cell Phone: ______________________
Work Phone: _____________________
Second parent/guardian or other emergency contact:
Name : _______________________________ Relationship to participant: __________________________________
Home Phone: ______________________
Cell Phone: ______________________
Work Phone: _____________________
II. All participants in Summer programs are required to have Health Insurance, and must supply a copy of the
insurance card (front and back) with the form. Please complete the information below and attach a copy of the
insurance card.
Insurance Company Name:_______________________________
Policy Number :_____________________________
Policyholder’s Name:____________________________________
Group Number: __________________
A copy of the insurance card is attached
III. Consent for Evaluation/Examination/Treatment of participants under 18 years of age
I hereby grant permission to Rensselaer’s Student Health Center for evaluation, examination, and treatment of my child in the
event of medical illness or injury. I also authorize urgent treatment at Samaritan Hospital and other appropriate local
hospitals.
_______________________________________________ _____________________________
Signature of parent/legal guardian
Date
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IV. Meningitis Vaccination response (Required by New York State Law)
My son/daughter has had the bacterial meningitis vaccine, as indicated on the immunization record attached.
I have read, or have had explained to me, the information regarding bacterial meningitis disease. I understand the risk of not
vaccinating my son/daughter and have decided to decline vaccination at this time.
________________________________
Signature of parent/legal guardian
___________________________
Relationship to participant
_______________
Date
V. Health History: (To Be Completed by the Child’s Parent or Guardian)
Does your child have life threatening allergies to:
(please list specific allergen)
Medication
Food
Bee’s
Other
_______________________________
_______________________________
_______________________________
_______________________________
Does your child have or is subject to:
□Asthma □High Blood Pressure
□Seizures □Heart problems
□Diabetes
□Lyme Disease
□Dizziness/Fainting
□Headaches
□Kidney/Urinary Disorders □Other
Details__________________________________________________________________________________
VI. International Travel (required by Rensselaer Polytechnic Institute Health Center)
Have you or do you have plans to travel to any of the following countries between March 15-April 17, 2015: Guinea,
Sierra Leone, Liberia, Democratic Republic of the Congo, Ivory Coast, Ghana, Burkina Faso, Guinea-Bissau, Mali,
Senegal, The Gambia, Benin, Togo?
_____ YES
_____ NO
VII. Physical Examination (include with this form)
Each participant must provide a copy of a physical examination, school physical or sports physical signed by a health care
provider that was performed in the last two years.
VIII. Immunization Record (include with form)
Program participants must have all the immunizations required by the New York State Health Department for their age
and are required to provide a copy of their immunization records. Participants cannot participate in the program without
the dates being filled in completely. Writing “up to date” is NOT acceptable. Photocopies of physician office, health
department, or school immunization records are acceptable.
(Application for religious or medical exemption from immunization requirements can be requested and must be signed
and notarized). To request this form, please contact Alicia Randazzo at randaa2@rpi.edu, or (518) 276-6809.
IX. Medications
Please complete the Medication Form if your child will be receiving prescription or over-the-counter medications while
attending a Summer@Rensselaer program, or if you wish the Student Health Center to be able to administer medications
if necessary (see form).
*If your child plans to self medicate during his/her program please request the self-medication form. You can request this
form by contacting Alicia Randazzo, randaa2@rpi.edu or (518) 276-6809.
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Medication Form
This is for our health center for their records,
and per NYS Dept. of Health regulations.
Use one form per student *** Please make a copy for your records *** Complete and return to; Rensselaer Polytechnic Institute,
Academic Outreach Programs – Summer@Rensselaer - 110 8th Street – 1516 PE, Troy, NY, 12180-3590 USA
Student Name: _________________________________________________________
Program Name: ________________________________________________________
Parents/Legal Guardians must indicate, and the child’s health care provider must approve, whether they would like
Rensselaer to administer any medications.
*Upon check in, the student will be required to check their medication in with the nurse. The nurse will have reviewed this
form and will verify the medication at that time.
A. Prescription medication
Drug name
Dosage
Route
Schedule and indications
Comments
B. Over the counter medications
The following medications are available at the Student Health Center and will be administered at the discretion of a nurse if approval
is indicated by the camper’s health care provider. Any other over the counter medications the child routinely takes and will be
bringing must be added to this list. No over the counter medications can be dispensed without the completion of this section!
Drug
Dosage
Route
Schedule
Provider
Approval
Yes/No
Acetaminophen
(Tylenol)
Per label instructions by
age/wt
PO chewable
tabs, tabs, elixir
Q 4h prn pain or
temp ≥100.4
Ibuprofen
Per label instructions by
age/wt
PO chewable
tabs, tabs, elixir
PO chewable tabs,
tabs, elixir
Yes/No
Benadryl
Per label instructions by
age/wt
PO chewable
tabs, tabs, elixir
Q6h prn (allergic
Reaction)hives
Yes/No
Hydrocortisone
cream
Per label instructions by
age/wt
Per label
instructions
Bid prn rash
Yes/No
Antiobic ointment
Per label instructions by
age/wt
Per label
instructions
Bid prn minor
bacterial infections
Yes/No
Pepto Bismol
Per label instructions by
age/wt
PO chewable
tabs, tabs, elixir
Upset stomach
Yes/No
Insect repellant
Per label instructions
Topical
preventative
Yes/No
Sunscreen
Per label instructions
Topical
preventative
Yes/No
Comments
Other
C. Self Medication
If your child plans to self medicate during his/her program please request the self-medication form by contacting, Alicia Randazzo at
randaa2@rpi.edu or (518) 276-6809.
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D. Signatures required by the Student Health Center:
Parent/Guardian signature:
Date:
Health Care Provider (MD, PA, NP) Name:
Phone:
Health Care Provider (MD, PA, NP) Signature:
Date:
Rensselaer Polytechnic Institute – Summer@Rensselaer
PROGRAM RULES & REGULATIONS FORM
Use one form per student *** Please make a copy for your records *** Complete and return to; Rensselaer
Polytechnic Institute, Academic Outreach Programs – Summer@Rensselaer - 110 8th Street – 1516 PE, Troy,
NY, 12180-3590 USA or fax to (518) 276-8738.
1.
Due to the intensity and progressive nature of our curriculum, students must attend all classes, laboratories, and scheduled
tutorials, seminars, workshops and meetings unless excused by the Program Staff.
2.
It is expected that all students honor quiet hours as outlined by staff.
3.
In order to safeguard the privacy and safety of the residents, students may not have visitors of the opposite gender in their
rooms. Further, curfew will be strictly enforced.
4.
Modern kitchen facilities are available for your use; it is expected that you clean up after yourself immediately before leaving
the kitchen area.
5.
Any participant who does not conduct himself or herself in an appropriate manner or who is disruptive to the instructor
and/or fellow participants will be dismissed from the program. It is up to the Instructor to decide what constitutes as
disruptive behavior. If a student is disruptive, the parent/guardian will be notified and will need to come immediately to
campus to pick up the student.
6.
In accordance with New York State Law and Rensselaer policy, no alcoholic beverages or illegal substances will be allowed
on campus. “Campus” refers to any property owned and operated by Rensselaer within Troy’s main campus. Further, these
rules and regulations apply to any Summer@Rensselaer sponsored event. If caught with any illegal substance or alcohol, the
student’s parent/guardian will be notified and the student will be asked to leave the program. Summer program staff must be
alerted to prescription medications to be taken during residence on campus.
7.
All Rensselaer facilities are open for student access except where restricted.
8.
Students will not be able to leave campus during the week without written or verbal parental consent. If you must leave the
campus for any reason, your parent or guardian must contact the Academic Outreach Programs Office at (518) 276-6809 to
make arrangements for pick-up on campus.
9.
Students are required to follow all rules and regulations of the Summer@Rensselaer Program and Rensselaer Polytechnic
Institute. It is the student’s responsibility to attend to rule
up-dates and notices posted on residence hall bulletin boards
near the bathrooms or a staff member’s room door on each floor.
10. Participants are responsible for the safekeeping of their personal belongings. Rensselaer is not responsible for theft or other
losses of, or damages to, students’ personal belongings, including athletic equipment, musical instruments, iPods & MP3
Players, cell phones and computers. When considering whether to bring an expensive item, families may wish to investigate
possible coverage under their own homeowner’s or renter’s insurance.
STATEMENT OF ASSURANCES AND UNDERSTANDING OF RULES & REGULATIONS:
I understand and accept the Rules & Regulations. I also understand that failure to abide by these rules and
regulations outlined above could result in expulsion from the program without a refund.
____________
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Student Name (Please print if applicable)
Student Signature
Date
____________
Parent or Guardian Name (Please print)
Parent or Guardian Signature
Date
Rensselaer Polytechnic Institute
ASSUMPTION, RELEASE AND INDEMNITY AGREEMENT
I, ______________________________, am a willing participant in the above-named event, and fully understand that there
may be risks inherent in or associated with my participation in this residential activity. I hereby ASSUME ANY AND ALL RISK of
bodily and personal injury, death, and damage to personal property, whether known or unknown, foreseen or unforeseen inherent in or
associated with participating in this activity. Furthermore, I hereby RELEASE FROM LIABILITY and agree to INDEMNIFY
AND HOLD HARMLESS Rensselaer Polytechnic Institute, its trustees, students, agents, and employees, for claims of any kind for
known or unknown, foreseen or unforeseen bodily and personal injuries, death or damage to property which may arise, result from, or
be associated with my participation in this activity.
I understand that this is an ASSUMPTION OF RISK and RELEASE FROM LIABILITY that will legally PREVENT me or any
other person claiming under me from filing suit or making any other legal claim for bodily and personal injury, death, or damage to
personal property sustained by me. I, nevertheless, enter into this agreement freely and voluntarily and agree that it is binding on me,
my heirs, assigns, and legal representatives.
VIDEO SERVICES
In consideration of value received, the receipt of which is hereby acknowledged, I hereby give RENSSELAER POLYTECHNIC
INSTITUTE, its legal representatives and assigns, and those acting with permission of Rensselaer Polytechnic Institute or employees
of Rensselaer Polytechnic Institute, the right and permission to copyright and/or use, reuse and/or broadcast and republish still
photographs, motion pictures, digital media, videotapes and/or associated or independent audio recordings of me, on reproductions
thereof in color, or black and white made through any media, for any purpose whatsoever, including the use of any printed matter in
conjunction therewith.
PLEASE CHECK WHICH APPLIES:
________I hereby waive any right to inspect or approve the finished still photographs, motion pictures, digital media, videotapes
and/or associated or independent audio recordings, or advertising copy or printed matter that may be used in conjunction therewith or
to the eventual use that it might be applied.
_______I hereby release, discharge and agree to save harmless Rensselaer Polytechnic Institute, its representatives, assigns,
employees or any person or persons, corporation or corporations, acting under its permission or authority, or any person, persons,
corporation or corporations, for whom it might be acting, including any firm publishing and/or distributing the finished product, in
whole or in part, from and against any liability as a result of any distortion, blurring or alteration, optical illusion, or use in composite
form, either intentionally or otherwise, that may occur or be produced in the taking, processing or reproduction of the finished product,
its publication, distribution or broadcast.
I have read and agree to the above statements:
__________________________________________
Student Signature
__________________________
Date
If student is under 18:
As the legal guardian of this student, I join in and agree to be bound by this release/hold harmless document.
__________________________________________
Legal Guardian if Student is under 18.
___________________________
Date
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___________________________________
Relationship to Student
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