Medical Information forms

  • 2016 STUDENT ORGANIZATION TRIP – DC

     HEALTH HISTORY - PERMISSION SLIP

     

     

    STUDENTS NAME_______________________________________________                     DATE OF BIRTH__________________

    PARENTS NAME________________________________________________                     PARENT PHONE #_______________

    PARENTS NAME________________________________________________                     PARENT PHONE #_______________

    PLEASE COMPLETE THIS BRIEF MEDICAL HISTORY:

    ASTHMA_______   IF YES PLEASE LIST MEDICATION (S)________________________________________________________

    LIFE THREATENING ALLERGY (PLEASE LIST ALLERGY PEANUTS, BEESTING ETC.)______________________________________

    IF YES PLEASE LIST MEDICATION(S)_________________________________________________________________________

    EPILEPSY/FAINTING/SEIZURE____________IF YES PLEASE LIST MEDICATION(S)______________________________________

    DIABETES_________IF YES PLEASE LIST MEDICATION(S)_________________________________________________________

    HEART DISEASE_______IF YES PLEASE LIST MEDICATION(S)______________________________________________________

    RECENT HOSPITALIZATION OR SURGERY, IF YES PLEASE EXPLAIN__________________________________________________

    DIFFICULTIES SUCH AS BED WETTING, NIGHTMARES OR SLEEPWALKING_______________________

    IF YES PLEASE EXPLAIN___________________________________________________________________________________

    TAKE DAILY MEDICATION – EITHER PRESCRIPTION OR OVER THE COUNTER? __________________

    PLEASE LIST ONLY IF THIS MEDICATION WILL BE GIVEN ON TRIP __________________________________________________

    MEDICAL BULLETIN

    IN ORDER TO ASSURE A HEALTHY, AS WELL AS A HAPPY TRIP, WE URGE YOU TO CAREFULLY READ THIS BULLETIN.  If your child is under prescribed medication including over the counter medication, it will be necessary to have the permission form and medication brought in to Mrs. Moschetti.  No medication will be accepted without proper medical orders (see enclosed form).  The medication must include the student’s name, name of the medication, dosage and the doctor’s name and phone number.  If you have any questions, please call Mrs. Moschetti (914) 257-5790.  Thank you.

     

    In the unlikely event that your child develops a serious illness or has an accident, he/she will be taken to the nearest hospital.  Please provide the following information:

    HEALTH INSURANCE COMPANY:________________POLICY #__________________________________

    I GIVE PERMISSION FOR MY CHILD, _____________________________ TO ATTEND THIS TRIP AND TO RECEIVE MEDICAL ATTENTION IF DEEMED NECESSARY

    _______________________________________________

    PARENT SIGNATURE