Microsoft word - emergency medical form.doc

EASTLAKE NORTH HIGH SCHOOL BANDS
EMERGENCY MEDICAL INFORMATION
PLEASE BE THOROUGH IN FILLING OUT BOTH SIDES
RETURN TO EITHER DIRECTOR COMPLETED, SIGNED AND NOTARIZED PRIOR TO
THE FIRST SUMMER PRACTICE.
STUDENT INFORMATION
NAME:____________________________________ BIRTH DATE ________________ AGE_______ HOME PHONE _____________________
HOME ADDRESS _______________________________________________________
FAMILY DOCTOR________________________ PHONE_______________________
FAMILY DENTIST________________________ PHONE_______________________
II.
PARENT/LEGAL GUARDIAN
NAME__________________________________________________________________
ADDRESS (IF DIFFERENT) _______________________________________________
FATHERS WORK PHONE_______________________EMPLOYER _______________
MOTHERS WORK PHONE_______________________EMPLOYER ______________
OTHER EMERGENCY PHONE_____________________________________________
III.
OTHER EMERGENCY CONTACT (OPTIONAL)
NAME___________________________________ PHONE_______________________
NAME___________________________________ PHONE_______________________
IV.
INSURANCE INFORMATION
PROVIDER_____________________________ CERTIFICATE #__________________ GROUP____________________________ SUBSCRIBER I.D.____________________ ***PLEASE ATTACH A COPY OF THE INSURANCE CARD*** HEALTH/MEDICAL HISTORY
ALLERGIES (LIST) _________________________________________________________
__________________________________________________________________________
DENTAL PROBLEMS _______________________________________________________
_____________________________________________________________________
MEDICAL CONDITIONS THAT MAY BE AFFECTED BT THE PHYSICAL NATURE OF
MARCHING BAND_______________________________________________________
___________________________________________________________________________
CHRONIC MEDICAL CONDITIONS: (CIRCLE OR LIST)
ASTHMA DIABETES SEIZURES HIGH BLOOD PRESSURE HEART PROBLEMS
OTHER/PLEASE EXPLAIN ___________________________________________________
_____________________________________________________________________________________
_________________________________________________________________
CURRENT MEDICATIONS___________________________________________________
_____________________________________________________________________________________
_________________________________________________________________

ANY OTHER SPECIAL MEDICAL CONDITIONS THAT NEED TO BE STATED:
___________________________________________________________________________________________
___________________________________________________________________________________________
_____________________________________________________________
TO GRANT/DENY CONCENT
PURPOSE: TO AUTHORIZE THE PROVISION OF EMERGENCY TREATMENT FOR BAND MEMBERS, CHAPERONES, OR STAFF WHO BECOME ILL WHILE TRAVELING WITH OR IN THE COMPANY OF THE EASTLAKE NORTH HIGH SCHOOL BAND WHEN RELATIVES CANNOT BE REACHED PART A OR B MUST BE COMPLETED:
______________________________________________________________________________
PART A: TO GRANT CONSENT
IF ATTEMPTS TO CONTACT THE INDIVIDUALS LISTED ABOVE HAVE BEEN
UNSUCCESSFULM I HEREBY GIVE MY CONSENT FOR:
1. THE ADMINISTRATION OF ANY TREATMENT DEEMED NECESSARY BY DR. -
________________________(PHYSICIAN) OR DR. ___________________ (DENTIST), OR IN THE
EVENT THE DESIGNATED PREFERRED PRACTIONER IS NOT AVAILABLE, BY ANOTHER
LICENSED PHYSICIAN OR DENTIST; AND THE TRANSFER TO
_______________________________ (PREFERED HOSPITAL) OR ANY HOSPITAL
REASONABLY ACCESSIBLE.
THIS AUTHORIZATION DOES NOT COVER MAJOR SURGERY UNLESS THE MEDICAL
OPINIONS OF TWO OTHER LICENSED PHYSICIANS OR DENTISTS, CONCURRING IN THE
NECESSITY FOR SUCH SURGERY, ARE OBTAINED PRIOR TO THE PREFORMANCE OF SUCH
SURGERY.
DATE_______ PARENT/GUARDIAN SIGNATURE ________________________________________ ______________________________________________________________________________ PART B: REFUSAL TO CONSENT TO TREATMENT
***** DO NOT COMPLETE PART B IF YOU HAVE COMPLETED PART A *****
I DO NOT GIVE MY CONSENT FOR EMERGENCY MEDICAL TREATMENT. IN THE EVENT OF ILLNESS OR INURY REQUIRING EMERGENCY MEDICAL OR DENTAL TREATMENT, I WISH THE SCHOOL AUTHORITIES TO TAKE NO ACTION OR TO: __________________________________________________________________________________________________________________________________________________________________________ PARENT/GUARDIAN SIGNATURE_______________________________ DATE_______ OVER THE COUNTER MEDICATIONS
OFTEN TIMES, AS THE BAND TRAVELS, STUDENTS BECOME ILL. THE MEDICATIONS LISTED BELOW WILL BE SUPPLIED TO YOUR STUDENT BY THE CHAPERONES UPON STUDENT REQUEST. I GIVE MY PERMISSION FOR THE ADMINISTRATION OF THE FOLLOWING OVER-THE-COUNTER MEDICATIONS TO MY SON/DAUGHTER AS NEEDED PARENT SIGNATURE___________________________________________DATE_______ _______ACETAMINOPHEN (TYLENOL) _______IBUPROFEN (ADVIL OR MOTRIN) _______BONINE OR DRAMAMINE (MOTION SICKNESS) _______ANTACID (TUMS) MEDICATIONS WILL BE GIVEN AT THE MANUFACTURER’S RECOMMENDED DOSEAGE UNLESS OTHER
WISE INDICATED HERE.
PLEASE HAVE THIS FORM NOTARIZED HERE:
SWORN TO AND SUBSCRIBED IN MY PRESENCE THIS ____________ DAY OF _____________________
OF THE YEAR

EXPIRATION DATE_________________________
______________________________________________
NOTARY PUBLIC

Source: http://www.northhighmusic.com/resources/EMERGENCY+MEDICAL+FORM.pdf