USCGA-AIM3 Medical History and Clearance Form

Medical History
and Clearance
Form
AIM - 3

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AIM Coordinator (tw-c)
U.S. Coast Guard Academy
31 Mohegan Avenue
New London, CT 06320
860-444-8503 (phone)
860-701-6700 (fax)
www.uscga.edu
AIM@uscga.edu

Privacy Notice. In accordance with 5 USC 552a(e)(3), the following
information is provided to you when supplying personal information to the USCG.
(1) Authority which authorizes the solicitation of the information: 14 USC 182.
(2) The Principal Purpose for this information is to ensure that an accurate medical
history is collected (and utilized) for all applicants during the USCGA AIM Program.
(3) Routine uses which may be made of the information: As background on
applicants for the selection process; to contact the applicant; to determine if there
are existing USCG records on the individual; in performance of the duties of officials
and employees of the USCG in managing the AIM Program and making AIM
appointments. (4) Disclosure of the information is voluntary, but the applicant will
not be considered further for the AIM Program if the information is not provided.

Please Select
Student’s Name: _______________________________________________________________________________________________
Last

First

M.I.

Gender

Date of Birth (i.e. 01 OCT 2001)

AIM Session (1, 2, or 3):

Each question (on both sides of this sheet) must be completely answered. Sections I and II must be filled out in their entirety by
the AIM student and a parent or legal guardian; Section III must be filled out in its entirety by a licensed Physician (MD or DO) or a
Physician’s Assistant or Registered Nurse Practitioner at said Physician’s direction.

SECTION I
AUTHORIZATION FOR MEDICAL TREATMENT
I (we), the undersigned, am (are) the parent(s) and/or legal guardian(s) of the above named student, a minor, being under the age
of eighteen (18) years. I (we) have specifically granted my (our) said child permission to attend the U.S. Coast Guard Academy
AIM Program to be held at the U.S. Coast Guard Academy in New London, Connecticut in July 2017.
To the best of my (our) knowledge and belief, my (our) said child has no mental or physical defects, diseases or impairments, and
during such program he/she may engage in all physical activities, including drills, exercises, and sports. Without limiting the
generality of the foregoing, I (we) specifically verify that the medical history information previously submitted with said child’s AIM
application is complete and accurate, and that said information is unchanged as of the date we sign this authorization. We agree to
notify the Admissions Office of any change therein that occurs from now until said child’s arrival at the U. S. Coast Guard
Academy for AIM 2017.
In the event my (our) said child should become ill or injured while participating in this program, including the period of time while my
(our) said child is traveling from his/her place of residence to the U.S. Coast Guard Academy, while at the U.S. Coast Guard
Academy, and returning from the U.S. Coast Guard Academy to his/her place or residence, I (we) hereby authorize all medical
personnel, including but not limited to physicians, physician assistants, nurse practitioners, athletic trainers and other health
personnel working at the U.S. Coast Guard Academy’s direction to administer drugs, medication (prescription or over-the-counter),
blood, and medical treatment, including emergency first aid and surgery which, in the judgment of any of the above, is necessary
or desirable to protect the life, health, well-being, or safety of said child. All decisions concerning medical treatment of all types
may be made by such medical personnel. Except for first aid, immediate emergency treatment, and ongoing evaluation and
treatments by licensed athletic trainers, all AIM students will be transported to local emergency rooms, physician offices, or walk-in
clinics at the expense of the parent or guardian for medical treatment. Students will not be treated on base or by Coast Guard
personnel, except as stated above.
I (we) further agree that any and all medical treatment deemed to be necessary and appropriate, in the opinion of such medical
personnel, may be undertaken without notification to me (us). I (we) further represent and agree that, in the exercise of the
discretion in selection of medical facilities, medical personnel, the U.S. Coast Guard, the U.S. Coast Guard Partners and the
officers, members, personnel and employees thereof, are hereby released, indemnified and held harmless from any loss of liability
they, or any of them may incur or suffer by virtue of acts or omissions in pursuance of the premises herein set forth. I (we) further
agree to reimburse the said U.S. Coast Guard, U.S. Coast Guard Partners and the officers, members, personnel and employees
thereof, for any and all costs and expenses they, or any of them, may incur, in connection with such medical treatment.
I (we) agree that a photocopy of this original signed form shall have the same validity as said original.

PARENT/GUARDIAN SIGNATURE

DATE

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SECTION II

EMERGENCY CONTACT INFORMATION AND MEDICAL HISTORY

PARENT/GUARDIAN HOME MAILING ADDRESS:

HOME TELEPHONE NUMBER: _______________________________________
E-MAIL ADDRESS: _____________________________________________

ALL CELL PHONE NUMBERS (WITH NAMES): _______________________________________________

ALL WORK TELEPHONE NUMBERS (WITH NAMES): _________________________________________________

IF MEDICAL PERSONNEL ARE UNABLE TO CONTACT PARENT/GUARDIAN, ANY OF THESE OTHER PERSONS ARE

AUTHORIZED TO SPEAK AND ACT ON OUR BEHALF:

NAMES
RELATIONSHIP
ALL PHONE NUMBERS

MEDICAL INSURANCE COVERING CHILD (STUDENTS MUST HAVE MEDICAL INSURANCE TO PARTICIPATE IN AIM):
POLICY #
COMPANY
STUDENT’S MEDICATION, FOOD, OR OTHER ALLERGIES:
(WRITE “NONE” IF THAT IS THE CASE)
PARENT/GUARDIAN SIGNATURE

DATE

1. Do you have any limitations or disabilities that may impact your participation in the AIM program?

Yes

No

 If Yes, give details _________________________________________________________________________________________
2. Do you have, or have you ever had, an adverse reaction to any medicine, drug, stinging insect, food product, or other
substance or environmental condition?
Yes
No
 If Yes, what was the reaction to? ______________________________________________________________________________
 Was the reaction life-threatening, (for example, difficulty breathing, obstructed air-way, shock, cardiac trouble) i.e., a true allergy,
OR was it less severe (for example, rash, nausea, itching) ________________________________________________________
 If you carry an EPI-PEN, make sure you bring it with you.
3. In the last two years, has a doctor or other medical professional ever denied or restricted your participation in sports for
more than one day?
Yes
No
 If Yes, when and why? _____________________________________________________________________________________
4. During or after exercise, have you ever
A. Passed out or nearly passed out?

Yes

No

B. Had pressure in your chest?

Yes

No

C. Had your heart skip beats?

Yes

No

 If you answered Yes to A, B, or C, please describe what happened __________________________________________________
_______________________________________________________________________________________________________

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5. Do you cough, wheeze, or have difficulty breathing during or after exercise?

Yes

No

 If Yes, give details ________________________________________________________________________________________
6. Have you ever used an inhaler or taken asthma medication after the age of 13?

Yes

No

 If Yes, give details, including when ___________________________________________________________________________
 If you are currently using an inhaler, make sure to bring it with you.
7. Within the past two years, have you been hospitalized, prescribed medication, placed on a special diet, or given any

limitations of physical or other activity?
Yes

No
 If Yes, what, when and why? _________________________________________________________________________________
_________________________________________________________________________________________________________
8. Are you currently taking any prescription or over-the-counter medications?

Yes

No

 If Yes, what and how often? _________________________________________________________________________________
 If you are taking prescription medication, make sure to bring with you a copy of the prescription and a week’s supply of
the medication.
9. Have you ever had surgery?


Yes

No

If yes, what problem, what procedure, and when performed? _____________________________________________________

10. In the past year have you had a head injury that was diagnosed as a concussion, or that caused you to lose consciousness,
to have memory loss, or to have headaches for more than two consecutive days?
Yes
No


If yes, give details, including when __________________________________________________________________________

11. Have you ever had a seizure after the age of 5?


Yes

No

If yes, give details, including when __________________________________________________________________________

DATE SIGNED: ________________________. We, the undersigned AIM student and parent/guardian, each state under oath that
to the best of our knowledge our answers to the above medical questions are complete and accurate. We each agree to
notify the Admissions Office of any change in the history or of any medical treatment received by the student since the date of
our signing this form AND since the date of the physician’s examination described below.

______________________________________

_____________________________________

Printed Name of AIM Student

Printed Name of Parent/Guardian

____________________________________________
Signature of AIM Student

___________________________________________
Signature of Parent/Guardian

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SECTION III
PHYSICIAN CLEARANCE
I certify that:

1) I am an MD or DO (or a Physician’s Assistant or Registered Nurse Practitioner under MD or DO direction) duly licensed to
practice by the State or Commonwealth of __________________________

;

2) I understand that the student will be participating in daily vigorous physical and mental activity for a one week period
in Connecticut in July, 2017;

3) I have on this date reviewed the medical history of the named AIM student furnished above and on the reverse side.
4) I represent that either “A” or “B” below (please check one or the other) is true:
A. I physically examined said student today; OR
B. I examined said student on or after August 1, 2016; AND

5) based on said review, examination results, and understanding, this student is cleared to participate in said activity with:
(check one)
No physical, mental or dietary restrictions

The following restrictions: (provide specifics below)

Examiner’s printed name and title: _______________________________________________
Examiner’s full address, telephone number, and fax number:

Examiner’s signature: _____________________________________

Examiner's Office stamp:

Date signed: ______________________________________

PLEASE EMAIL THIS COMPLETED FORM TO AIM@USCGA.EDU BY JUNE 1

OMB Control No.: 1625-0121
Expiration Date: 05/31/2018
PRA Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless
it displays a valid OMB control number. The United States Coast Guard estimates that the average burden per response for this report varies
per applicant - about three hours for completion of the online application, including personal statements, and up to two hours to complete all
supplemental forms. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the
burden to: U.S. Coast Guard Academy, Admissions Office, 31 Mohegan Avenue, New London, CT 06320 or Department of Homeland Security
Desk Officer, Office of Management and Budget, Office of Information and Regulatory Affairs, Washington, DC 20503.