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Applicant's Preliminary Medical Questionnaire

Have you been hospitalized overnight in the past 5 years?*
Have you had surgery in the past 5 years?*
Are you missing any paired organs such as kidneys, lungs, testicles, etc.?*
Have you ever passed out during exercise?*
Have you had a head injury in the past 5 years that resulted in a concussion or unconsciousness?*
For example: 2021-football game-mild concussion; 2020-skateboarding-severe concussion, hospitalized; 2019-car accident-unconscious no treatment
Have you ever had heat exhaustion, heat stroke or heat cramps?*
Have you ever experienced numbness or tingling in your arms, hands or feet?*
Do you have allergies to any medications?*
For example: Penicillin-hives-mild; Aspirin-stomach upset-severe
Do you have allergic reactions to insect bites, bee stings, pollen or latex, etc.? *
For example: Dust/pollen-sneezing and coughing-mild with medication; Bee sting-anaphylactic shock-life threatening epi pen
Are you allergic to any foods?*
For example: Strawberries-hives-mild with medication; Milk and all milk products except cheese-stomach cramps-moderate to severe; Gluten-Celiac disease-severe diet restrictions
Do you take any regular or intermittent prescription medications? List all. *
For example: Albuterol-Asthma-inhaler as needed; Doxcycline-Acne-2 times per day
Do you have all the immunizations required to attend a Washington State public school? *
WYCA Health Center staff will verify immunizations for all applicants through the Washington Department of Health database.

Applicant's Preliminary Medical Questionnaire - Continued

Have you ever been diagnosed/treated for ADD or ADHD?*
For example: I was diagnosed in 6th grade. I function fine when I take the medication ; I was diagnosed 2nd grade and I don't have this any more; I was diagnosed last year and I don't take the medication because I don't like the way it makes me feel.
Do you have a history of violent outbursts or difficulty managing your anger?*
For example: I get really mad when things don't go my way-punch holes in the wall
Have you attempted suicide within the last 12 months?*
For example: I attempted suicide in 2020 because my brother died. I never went to the hospital and I don't see a counselor because I'm better now. Another example: I attempted suicide in April when I took pills. My mother found me and I went to the hospital. I have been seeing a counselor for the past 4 months. I'm figure this out.
In the last 5 years have you been diagnosed or treated by your doctor or a behavioral health professional for mental health reasons? *
In the last 5 years, what did your doctor or a behavioral health professional diagnose/treat you for: *
Check all that apply.
Have you ever been prescribed medication for behavioral health reasons, regardless of whether you took it or not?*
For example: I was 12 years old and depressed. I can't remember the medication name, but I took if for a few weeks and now I don't take it anymore. Another example: I currently take medication for anxiety.

Medical Information and Signatures

Limited Medical Services

  The Washington Youth ChalleNGe Academy is NOT a hospital, medical, dental or mental health clinic. We have a licensed nurse on staff. For this reason, we are unable to accept applications from Applicants who require ongoing medical, behavioral health counseling services or dental care for conditions that originated prior to arrival at the program or that develop after enrollment that prevents their full participation on a daily basis. Minor illnesses and injuries that arise during the program are handled on a “sick call” basis. Cadets with more serious illnesses or injuries will be taken to a local clinic or hospital emergency room as appropriate. Please note, if the illness or injury is serious, it could jeopardize the Cadet’s continued enrollment. The WYCA does not have staff available to transport Cadets to frequent medical, dental or vision appointments or provide ongoing treatment. Cadets with medical issues that will impact their daily participation will be dismissed and sent home. The Cadets can reapply to a future class and compete for admission as long as they are in good standing in all other areas. Any periodic appointments for preventative medical, dental or vision care must be made when the Cadet is at home during a scheduled break or “home pass”.  Appointments scheduled while on home pass should not overlap with the Cadet’s scheduled time for return, as this will put the Cadet at risk of not completing the required training and attendance for successful completion. These policies and procedures are intended and designed to ensure the safety, health and welfare of the Cadets and staff of the WYCA.

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Medical Documentation Necessary to Complete Application

Additional medical paperwork is required for Admissions. This additional paperwork can be found on the website and will be emailed to you.  A completed physical exam by a licensed medical professional must be completed no more than 1 year from the start of the program.  The physical exam and accompanying documents must be submitted to be considered for Admission.  A dental exam must be completed no more than 1 year from the start of the program.  All necessary dental work must be completed before the start of the program.  

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