Boston schoolmed


Youth organizations using the school forest must use this form. This health information
must be on file at the school forest during the time that the group is using the facility. This
form must be kept by the youth group leader for 2 years.
Name __________________________________ Age ____________ Phone _____________________
Address ___________________________ City _____________________ State ______ Zip _______
Organization __________________________________________ Date of Program _____________
Emergency Contact Person ________________________________ Phone ____________________
Insurance Company ___________________________ Identification Number _________________
Does the camper take any medication(s)? Yes ______

My child has my permission to receive emergency medical care:


1. All medications (including over the counter pills, vitamins and treatments) must be
turned over to the health care supervisor upon registration.
2. All medications will be administered under the direction of the health care staff.
3. All medications should be labeled clearly with the camper’s name, name of the drug,
dosage and time to be taken. Please provide an adequate supply.
4. Do not record insulin schedule below.
Dosage Date Time Date Time Initials
Comments: __________________________________________________________________________ _____________________________________________________________________________________
5. Does the camper experience any side effects from the medication?
Yes ______ No ______ (i.e.: mood or behavior changes, upset stomach, diarrhea, etc.)
If yes, what should be done about this? _____________________________________________
6. List below any special instructions or additional information regarding the medication
that would be helpful to the health care supervisor. _________________________________
7. Allergies: Do you have any allergies (e.g. bees, drugs, food, etc.)? If so, what are they?
8. Medications: Are you taking medication (e.g. Tylenol, Orthonovo 777, Proventil, etc.)?
If so, what are they? What are they for? ___________________________________________
9. Chronic Illness: Do you have any chronic illness (e.g., diabetes, epilepsy, asthma,
etc.)? ____________________________________________________________________________
10. Physical Conditions: Do you have any physical conditions that might limit or prevent
you from participating in certain physical activities? If so, please describe. ___________
11. Injuries: Have you experienced any injuries (e.g. dislocations, sprains, etc.) within the
last three years? If so, list here and identify when the injuries occurred and the extent
or the severity of the injury. Have you fully recovered from this injury? ______________
12. Physician: Have you been treated by a physician in the past year? Have you been
hospitalized within the past year? If so, explain. ___________________________________
Have you had any of the following in the last 24 hours?


Mountain Range Dentistry PATIENT INFORMATION PATIENT’S NAME LAST______________________________FIRST______________________________MI_____DATE ___________ GENDER (M) (F)_____AGE___________BIRTHDATE__________________ DRIVER’S LICENSE NUMBER_____________________ ADDRESS______________________________________________CITY__________________________STATE__________ZIP__________ PARENT

The please don't forget me list

The Please Don't Forget Me List Sacred Sites of Peru & Machu Picchu; Merging with the Divine October 7th-18th, 2009 Led by: Sheri Rosenthal DPM I am so delighted that you are joining us for the upcoming excursion! I ask you to carefully read the following information to ensure that your experience is as physically comfortable and spiritually rewarding as possible. Each Jou

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