Inter-Varsity Christian Fellowship of the United States of America

d/b/a Campus by the Sea

Medical History

Name: ________________________________  Date of Birth _________ Age _______ Sex _____

Address __________________________________________________________________________
                (street)                (city and state)                  (zip)

Allergies: Check and specify any reaction to Penicillin _________________________________________

Other Drugs ________________________________ Insect Bites _______________________________________

Any reason for limited activity? Please specify _______________________________________________________

If Under care of physician in the past 3 years for medical, surgical, or emotional
reasons,  please provide general information. ________________________________________________________

Current Medication Required? Specific drug and dosage __________________________________
Past/Present Illness or injury: Check and the date
________ allergies (asthma, hay fever, eczema, others)              
________ major accident                ____________ sinus trouble
________ mumps                         ____________ convulsions/seizures
________ frequenct colds, sore throat  ____________ measles
________ major surgery                 ____________ headaches
________ chicken pox                   ____________ kidney/bladder trouble
________ fainting                      ____________ bronchitis
________ heart trouble                 ____________ abscessed ears
________ tuberculosis                  ____________ stomach upsets
________ night sweats                  ____________ mononucleosis     
________ joint injury/disease          ____________ diabetes: controlled by diet? 
________ oral medication               ____________ insulin
Immunization and tests: Check if current

________ tetanus: date _________          ___________ diphtheria
________ polio                            ___________ typhoid
________ tuberculin                       ___________ others

If over 18, please sign _______________________________  Date: _____________

Parent's Consent for Emergency Treatment

The under-signed hereby authorizes Campus by the Sea's director or representative to obtain such medical Aid or assistances as might be required for the immediate care of my son/daughter/other in the event of an emergency. This permission will include the administration of medicines, surgical treatment, X-ray examination, or hospitalization such as might be ordered by a duly licensed medical doctor. In no event will Campus by the Sea, its officers or representatives, be held liable for any first aid rendered or treatment performed pursuant to this consent. This authorization shall remain effective during 2003.

Signed _______________________________________________ Date __________________

In case of emergency, please notify:

1. Name ____________________________ Home Phone ___________ Work Phone __________
2. Name ____________________________ Home Phone ___________ Work Phone __________