Rotary District 7430 & STEM YEA Youth Explorer Academy

Mission to Mars · June 24–27, 2027

Student Health History

Read only by our Doctor and the STEM YEA Program Manager. Dining Hall Services are notified of any allergies or dietary restrictions. This takes about ten minutes, and replaces the paper health history form.

Questions? health@stemyea.com

* indicates a required answer

The student

So we can match this to their registration.

Student’s full name *

Date of birth *

School *

Sponsoring Rotary club

Who we call

Three people, in the order we would try them.

Name {{c.reqMark}}

Relationship to student

Mobile phone {{c.reqMark}}

Allergies, diet and medication

Allergies, diet and any medication your child takes.

Does your child have any allergies? *

Yes No

If yes, name each allergy and the reaction you have seen

Does your child carry any emergency medication?

An EpiPen — they will bring it and tell our nurse An inhaler — they will bring it and tell our nurse

Diet

Anything else our kitchen needs to know

Will your child take any medication during the Academy? *

Yes No

If yes, list each one — name, reason, dose and when it is taken Include vitamins and natural remedies. Send everything in its original labeled pharmacy container, enough for four days, and hand it to our nurse at check-in.

Is there any over-the-counter medication your child should NOT be given? Our nurse keeps these on hand and may give them as needed. Check any to withhold.

Immunizations

The fastest route is to attach the record you already have.

How would you like to give us this? *

I will email a copy of the immunization record — from our doctor, or the school nurse. Send it to health@stemyea.com and skip the dates below. I will type the dates below — most recent dose of each.

Most recent dose of each Month and year is enough. Leave blank anything your child has not had, or that you are attaching a record for.

All students must be up to date with their immunizations.

Health history

Check anything that applies, then tell us more below.

General health

Tell us about anything you checked

Learning, emotional and social This helps our faculty support your child. It is never used to screen a student out.

Tell us about anything you checked, and what helps

Primary doctor or practice *

Doctor’s phone *

What have we forgotten to ask? Anything about your child’s health, comfort or wellbeing that would help us look after them well.

Your confirmation

One box, and your name.

This health history is correct and accurately reflects my child’s health. I understand it will be shared with STEM YEA staff and volunteers on a need-to-know basis, and that our nurse and medical director may consult it at any time during the Academy. *

Your name *

Your email * We send your answers here so you have a copy.

One thing still to do on paper

Your child’s doctor must sign a short assessment confirming that the student can participate.

If you have a sixth-grade health form, please forward it to health@stemyea.com.

If you cannot provide a sixth-grade health form, open the Provider Assessment page, request the information from your doctor, and email the signed pages to health@stemyea.com.

Provider assessment page →

Nothing is saved until you press Submit.

STEM YEA · a program of Rotary District 7430 www.stemyea.com