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.
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In diesem Kapitel geht es um verschie-dene Krankheitsbilder und Beschwer-den an Haut und Haaren: Akne (S. 25), Lippenherpes (S. 37), Juckreiz/Ekzem (S. 49), trockene Haut (S. 61), Sonnen-brand (S. 68), Insektenstiche (S. 72),Pilzerkrankungen wie Fußpilz (S. 78), Nagelpilz (S. 84) und Pilz im Windel -bereich (S. 91) sowie übermäßigesSchwitzen (S. 105), Haarausfall (S. 109)u
MEDICAL RELEASE FORM