Microsoft word - 2012_medical_form.doc

MEDICAL RELEASE FORM
NAME _________________________________________ DATE OF BIRTH ________ ADDRESS ______________________________________PHONE _________________ CITY __________________________________________STATE_______ZIP ________ EMERGENCY CONTACT PERSON AND NUMBERS
BE SURE THAT THESE CONTACTS CAN SPEAK FOR YOUR OWN CHILD IN CASE OF EMERGENCY RELATIONSHIP
PHONE________
1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________
DOCTOR ______________________________________________PHONE__________
ADDRESS OF DOCTOR __________________________________________________ INSURANCE INFORMATION
COMPANY NAME _______________________________________________________ POLICY NUMBER _______________________________________________________ NAME OF ADULT CARRIER ______________________________________________ SIGNATURE __________________________________________DATE____________ PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARE WITH THIS FORM
HEALTH HISTORY
PLEASE LIST ANY MEDICATION, FOOD OR OTHE ALLERGIES GENERAL INFORMATION
PLEASE LIST ANY GLASSES, CONTACT LENS OR MEDICAL DEVICES NEEDED MEDICATIONS
Over the Counter medication: On occasion, students may become ill while participating in band functions. The Booster
Club keeps a limited supply of over the counter medicines on hand to make them comfortable until they get home, or until a parent arrives. Below is a list of the items that we attempt to keep on hand. The typical brands are for reference only. We will probably buy generics of most items to keep our costs down. A staff member or chaperone will control these, and a record will be kept when they are dispensed. If there are any items on the list that you do not want your child to have, please check the NO column.
Typical Brand
Antibiotic first aid cream
Neosporin
Ibuprofen pain reliever/fever reducer
Advil, Motrin
Acetaminophen pain reliever/fever reducer
Bismuth salicylate - upset stomach, etc
Pepto Bismol
Diphenhydramine HCL – allergic reaction
Benadryl
Loperamide HCL – anti-diarrheal
Natural Tear Eye Drops
Anti Nausea liquid
Cough Drops
Motion Sickness relief
Dramamine
Aloe Vera Gel – Sunburn care
Anti Itch Cream
Lanacaine
Fire Ant/Mosquito/Bee/Wasp sting relief
After Bite
Tums, Rolaids
Sun Screen – Each student is responsible for his/her own sunscreen. We Coppertone
would like to keep a bottle on hand in case someone forgets.
Prescription Medication:
If you would like to send prescription medicine for the staff/chaperones to hold for your child, a locked first aid case will be carried on trips. Please list them below. You must send the medicine in the original container with your child’s name and prescription details such as medicine name and dosage clearly marked. Any unused prescription medicines can be picked up at the end of the season. If your child uses an inhaler or epipen, you are encouraged to send a spare for us to ILLNESS AND SURGERIES
LIST ANY PAST SURGERIES OR ANY PREVIOUS ILLNESSES IMMUNIZATIONS
ARE YOUR IMMUNIZATIONS UP TO DATE? _______________________________ DATE OF LAST TENTUS SHOT __________________________________________ If a serious emergency arises, it may be necessary for a physician to attend to your son/daughter before the staff could get in touch with you or your designated physician. Such care can be provided only if you sign the following AUTHORIZATION FOR MEDICAL TREATMENT.

I give the teacher or administrator in charge of my son/daughter limited power of attorney to
act in my absence and see that my son/daughter __________________________________gets
whatever medical treatment necessary in case of sickness or accident.

The original of this form will be kept at the high school. Copies will be carried in each vehicle that transports
band students. If your child requires medical attention, a copy may be given to the medical professionals who
treat your child.

Source: http://greerbands.files.wordpress.com/2013/06/2013_medical_form.pdf