Provider Health Assessment

STEM YEA is a four-day, three-night residential STEM academy at Kutztown University. Students attend classroom and laboratory sessions, walk between buildings across campus, and take part in light outdoor recreation. A registered nurse is on site throughout, including overnight, with a physician serving as medical director. A physical examination within the last 12 months satisfies our requirement.

Parents: the family’s health history is submitted online at stemyea.com — these two pages are all your child’s doctor needs to complete. Fill in the box below, take both pages to the appointment, then email both back to health@stemyea.com. Page 1 is the page that gets signed; page 2 is the immunization record that travels with it.

Completed by the parent or guardian

Student name

Date of birth

Parent phone

Examination

Date of last physical

Height

Weight

Blood pressure

Clinical notes Attach a sheet if you need more room than these lines allow

Participation

Cleared without restriction Cleared with the restrictions noted below

Restrictions or accommodations

I have reviewed this student’s health history and, in my opinion, the student is physically and emotionally able to take part in the program described above, except as noted.

Provider name and credentials

Signature

Date

Practice and address

Phone

NPI or licence no.

Return both pages to health@stemyea.com Page 1 of 2

Immunization history Student

Health-care providers: photocopy the immunization history from the student’s record and attach it, or enter the dates below. Give the month, day and year of each dose. This mirrors page 3 of the Pennsylvania Physical Examination of School Age Student form.

Vaccine

Serology, if used

Antigen, date, and positive or negative — e.g. HepB, measles, rubella, varicella.

Disease diagnosed by a physician

Mumps, varicella or another vaccine-preventable disease, with the date.

All students must be up to date with their immunizations.

Return both pages to health@stemyea.com Page 2 of 2