B2 Medical Addendum

This form is being completed for:*

Applicant Enrolled Cadet

Last Name*

First Name*

Middle Name

1. During the past 12 months (since the last doctor physical) has your son:

a. been hospitalized?*

Yes No

b. had an injury requiring a doctor visit?*

Yes No

c. had an illness lasting more than one week?*

Yes No

If yes to any of the above questions, please provide date(s) and reason(s):

2. Does your son take any medication(s) regularly?*

Yes No

Daily Medication Fee (Non-Refundable): Daily medication(s) are administered three times per day during meals. A Cadet/Camper taking medication must report (as needed) to the MMA medical personnel during these scheduled time to receive medication(s). A Cadet/Camper cannot have prescription or over-the-counter medication(s) in their possession.

If yes, please list medication with corresponding diagnosis:

3. Is there a reason limits should be placed on your son's participation in sports?*

Yes No

If yes, please explain reason(s):

4. I affirm my child can swim or is not at risk of injury or death when swimming or otherwise accessing a body of water?*

Yes No

5. Do you prohibit your son from participation in contact sports such as football and/or boxing?*

Yes No

If yes, please explain reason:

6. Has your son had a concussion, fracture or been knocked out?*

Yes No

If yes, please explain reason(s) and date(s) of injury:

7. Has your son had convulsions, seizures, or been diagnosed with epilepsy?*

Yes No

If yes, please explain reason(s) and date(s) of occurrence:

8. Is your son currently undergoing or has he undergone psychiatric care?*

Yes No

If yes, please explain reason and include a letter along with three office notes from the psychiatrist/doctor:

Attachment

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attach letter along with three office notes from the psychiatrist/doctor

9. Is your son missing any organs?*

Yes No

If yes, please explain:

10. Is your son wearing a dental appliance? (i.e braces, retainer, etc..)*

Yes No

11. Has your son been treated for a back or neck injury?*

Yes No

If yes, please explain reason(s) and date(s) injury:

12. Is your son allergic to any medication(s)?*

Yes No

If yes, please list medication(s) with allergic reaction symptom(s):

13. Does your son have any condition or undergoing medical treatment not otherwise indicated?*

Yes No

If yes, please explain:

14. My son received a TB skin test on:

Result was negative on:

The primary purpose of a TB screening is to maintain a healthy and safe campus environment and to reduce the direct and indirect costs associated with a case of tuberculosis disease on campus.

Immunization Copy

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15. Parent permission for the Influenza vaccine.

I do I do not

Not applicable. My son has already received the influenza vaccine on:

The Influenza vaccine is at a cost of $25.00, billable to the parent/guardian. The Influenza vaccine will be given between October and November each year. It is NOT a required vaccine.

1. Has your Cadet had any immunizations this year that the MMA Medical Dept is unaware of?

Yes No

Attach copy of immunization record for update

No File Chosen

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All changes to your son's health must be reported to the MMA Medical Department to ensure no further injury or illness occurs and that treatment is either started or completed as prescribed.

This form is also required annually (for an enrolled Cadet) and must be received by the MMA Medical Department prior to participation in any sport, intramural activity, practice, or game either on or off-season.

The questions are designed to supplement the MMA Report of Medical History (doctor physical) that is required for initial enrollment. If changes occurred in your Cadet's health making it hazardous for him to participate, please note changes. All "YES" responses not previously addressed on the Report of Medical History form require a new doctor physical.

I certify all information contained on the Medical Addendum is true, complete and correct.*

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Date:*

Email

*to receive a system generated confirmation email.