Medical Information Part B – Email – Miami March of the Living

March of the Living 2022-2023 Application

Medical Form Part B: Medication and Mental Health

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

Medical Form Part A & B due by November 16th.

Physical Examination Form Upload due by January 2nd.

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Your teen is applying to participate in Miami's Leo Martin March of the Living 2022-2023 program. Miami’s March of the Living is an year long identity-building program that uses Poland and Israel as a platform to study the history of the Holocaust and examine the roots of prejudice, intolerance and hatred. Click Here for the program calendar for you to review to ensure your child can participate fully.

In order for their application to be complete, you, as the selected parent/guardian must complete the medical portion of the application. Part A & B should take you about 10 minutes to complete. We suggest using a computer and not a phone to access the form.

There are three parts of the medical paperwork:

Medical Form Part A
Medical Form Part B
Physical Examination Form Download and give to physician
Physical Examination Form Upload the completed form

Please complete all fields to the best of your ability.

*Denotes a required field

Be sure to enter your teen's email address below exactly how it appears in the email you received.

Registrant(Teen) Email Address^*

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":^*

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

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 Israel trip. Please provide additional information below and notify us if there is any change.

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.^*

Please print the physical medical examination form by CLICKING HERE

This form must be completed by the teen’s physician or nurse practitioner and returned by January 2, 2023.

Please note that your application will remain incomplete until this form is submitted.

Please scan and upload the document through your portal once it is completed.

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^*

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 January 2, 2023.^*

Yes. I understand.

If your teen is under the care of a psychiatrist, psychologist and/or social worker, they will need to complete THIS FORM

Mental Health Care Name^*

Mental Health Care Phone^*

Mental Health Care Email^*

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