2011-2012 medical release form

Calloway County Middle School Band
Student Name: ______________________________________________________ Grade Level: _____ last first middle Address: ____________________________________________________________________________ street or route city zip Birth date: __________________________________ Home Phone: _____________________________ Parent Work #: ______________________________ Parent Work #: ____________________________ Parent Cell #: _______________________________ Parent Cell #: _____________________________ Insurance Company: _________________________ Policy #: _________________________________ In case of emergency & parents cannot be reached, please notify: _______________________________ Relationship: _______________________________ Home Phone: _____________________________ Work Phone: _______________________________ Cell Phone: _______________________________ Health History Information:
1. Recent Illnesses (last 3 months): _______________________________________________________ _________________________________________________________________________________ 2. Chronic Illnesses: __________________________________________________________________ _________________________________________________________________________________ 3. Allergies: _________________________________________________________________________ 4. Medication taken on a daily basis: _____________________________________________________ 5. Other Info: ________________________________________________________________________ As a parent or guardian of _____________________________________________, I authorize treatment of the above-mentioned student by a qualified physician or nurse in the event the student should require medical treatment. I understand that should a serious or life-threatening medical emergency arise, initial treatment may be rendered by the individual, trained in first aid, if in the opinion of that individual, delay might endanger his/her life, cause disfigurement, or undue comfort. On the Medical Release Form, I have listed any allergies, ongoing medical treatment, or medical problems, which might influence treatment of the student. I will be responsible for charges incurred for the student’s treatment. This permission is granted with understanding that except in a serious medical emergency, a reasonable effort will be made to inform me prior to treatment. Parent/Guardian Signature: ________________________________________Date: ________________ These are “over the counter” products that are generally used by the school staff and chaperones. Please place a mark next to the over-the-counter medications that you give permission to be administered to your child by the school personnel and chaperones. Parent/Guardian Signature: ________________________________________Date: ________________ Mark all that you give permission to be administered to your child: ______ Ace Wrap ______ Acetaminophen (Tylenol) ______ Antibiotic Ointment ______ Aspirin ______ Baby Powder ______ Benadryl ______ Benadryl Cream ______ Calamine Lotion ______ Claritin ______ Cough Drops ______ Decongestant (Claritin) ______ Desitin ______ Dramamine ______ Hydrocortisone ______ Hydrocortisone Cream ______ Ice ______ Ibuprofen (Motrin, Advil) ______ Imodium ______ Maalox ______ Midol ______ Mylanta ______ Pepto Bismol ______ Saline ______ Throat Lozenges ______ Tums, Rolaids ______ Visine ______ Other ________________________________ COMMON  AILMENTS  &  OVER-­‐THE-­‐COUNTER  TREATMENTS  
Benadryl,  Hydrocortisone,  or  Benadryl  Cream   Headache,  Aches,  Pains   Acetaminophen  (Tylenol),  Ibuprofen  (Motrin,  Advil),  Midol  Irritated  Eyes   Calamine  Lotion,  Benadryl,  Baby  Powder,  Desitin,  Hydrocortisone  Cream   Mylanta,  Maalox,  Tums,  Rolaids,  Peptol  Bismol  

Source: http://beta.calloway.kyschools.us/Schools/Middle%20School/ksuiter/Documents/2011-2012%20Medical%20Release%20Form%20-%20Middle%20School.pdf


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