Health Information Form (Accomodations) | The National Inventors Hall of Fame

Health Information Form

If you would like to speak to someone to determine if our program is a good fit, please complete the form below.

Program Location

Program Start Date

Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

State

County

Child's Name

Please refer to our Essential Eligibility Criteria (EEC) stated in these Terms and Conditions, located on our website, for the minimum requirements that all participants must be able to meet, with or without reasonable accommodations, to participate in the Program.

I understand and agree to the Essential Eligibility Criteria

Personnel Limitations

Locations hosting summer/after-hours programs do not have the same personnel/tools available as they might during a typical school day. *Nurses, special education assistance, aides, etc., are not on site.*

PLEASE COMPLETE THE FOLLOWING INFORMATION REGARDING THE PARTICIPANT:

Please provide specific and detailed information regarding your child's needs during the Program in regard to:

Vision or hearing impairment

Yes

Allergy or dietary restrictions

Yes

Asthma/respiratory

Yes

Current, chronic, or episodic conditions
Such conditions may include, but are not limited to: diabetes, a heart condition, high blood pressure or other cardiovascular condition, orthopedic (joint or bone) injury, seizure disorder, mental/psychiatric conditions, emotional or behavioral conditions, self-harm, or substance abuse.

Yes

Medications

Yes

Medication, Dosage/Frequency, for what symptom/condition, side effects/effects of missed dose.

How the medication should be administered, including the approved administrator

Other

Does participant have any conditions or limitations (mental, physical, or emotional), described above or otherwise, that may necessitate care, affect their or other's well-being, or affect the participant's ability to engage in the Program activities?

YesNo

If Yes, please describe, and include any accommodations you consider appropriate.

Please list any observable symptoms, behaviors and/or triggering signs your child may show when they are in need of assistance and provide the preferred action plans, preventative techniques, de-escalation methods, interventions, etc.

Support Requested

My child could benefit from the below services while at camp:

If your child needs 1:1 or guidance support personnel, please list your approved Support Person below (including if self).

Support Person Name and Title

Support Person Phone Number

Support Person Email

Support Person approval is subject to local guidelines, site visitor restrictions, safety and security measures, background check criteria, etc.

Check here if you need assistance finding a Support Person (availability cannot be guaranteed).

Support Person Terms and Conditions

As the parent or guardian requesting a reasonable accommodation to enable your child to meet the Essential Eligibility Criteria necessary for participation in the Program, you acknowledge and agree:

1. The National Inventors Hall of Fame, Inc. ("NIHF"), its affiliated organizations, employees and associated personnel including the owners of the Program facility are released and discharged against any and all claims, liabilities and/or damages that arise as a result of the Support Person's participation in the Program. Support Person positions are on a volunteer or contracted basis, and no insurance will be provided by NIHF or any other party in relation to the Support Person's participation.

2. Support Person must complete the Program Team Member Agreement prior to the start date of the Program.

3. The Support Person is expected to adhere to an appropriate dress code as determined by the local level.

4. The Support Person personnel should refrain from text/talk/play on the phone while assisting during the Program. Cell phones should be used to communicate on an emergency basis and away from the group.

5. Corporal punishment or inappropriate contact of any sort with a participant or Program Team Member is strictly prohibited.

6. The purpose of Support Person assistance is to facilitate and aide the child as predetermined by the parent/guardian(s) in order to allow the child to meet the relevant Essential Eligibility Criteria.

7. You acknowledge that the Support Person may be in the position to supervise other participants of the Program as well as your child.

8. The Support Person and/or the child needing assistance should not disrupt, distract, or interfere with the standard operations of the integrity of the Program.

9. The Support Person shall not be alone with a child in restrooms or other areas unless preauthorized be the parent/guardian(s).

Confirmation

I certify that the information I have provided on this form is true, complete, and accurate. I agree to contact NIHF promptly if any of the information I disclose here changes before the start of the Program. I understand that providing inaccurate health information or falsifying health information can create serious risks to my child or others and may result in my child's dismissal from the Program. I acknowledge and agree to adhere to the aforementioned policies and no refunds will be given if a participant is dismissed due to their failure to meet the EEC, with or without reasonable accommodations. I understand my signature is valid and legally binding whether I choose to electronically sign, or manually sign a printable version of this Document.