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DAILY/PRN MEDS

C/O

RX

INI

NURSE’S SIGNATURE_____________________________________________________________________Initial_____

DATE/TIME

MEDICATION CHART

FOX CHAPEL AREA CHORAL TRIP

MEDICAL INFORMATION

NAME__________________________


Student Name___________________________Birthdate__________Grade________ Last First Address, City, State, Zip_________________________________________________ Father, Stepfather, Guardian (circle one)_____________________________________ Business Phone____________________________Pager_________________ Cell Phone______________________ Mother, Stepmother, Guardian (circle one)__________________________________ Business Phone____________________________Pager_________________ Cell Phone______________________

Please indicate if your child has any of the following health concerns: __Asthma

__Inhaler required

__Life-threatening allergy to bees

__Epi-Pen

__Benedryl

__Life-threatening food allergy

__Epi-Pen

__Benedryl

__Diabetes

__Date of Last Tetenus Shot_________

List any allergies to nuts (name specifically, e.g. “Peanuts), medications, etc. ____________________________________________________________________

If either Parent or Guardian cannot be reached, list two relatives or friends who may have the authority to advise regarding your child’s care: Name___________________________ Relationship to Child___________________ Home, Work and/or Cell Phone(s)_________________________________________ _____________________________________________________________________ Name___________________________ Relationship to Child___________________ Home, Work and/or Cell Phone(s)_________________________________________ _____________________________________________________________________ Family Physician________________________Phone________________________ Family Dentist__________________________Phone________________________ Name of Health Insurance Provider______________________________________ Phone#______________________________*D#___________________________ Group#_________________________ Is the student currently under medical treatment? _______Yes ________No If yes, nature of treatment, doctor’s name, and phone number: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ The Nurse has permission to administer the following medications: (please check all that are allowed) ___Tylenol ___Advil ___ Tums ___Midol _____Immodium ____Dramamine Signature of Parent/Guardian_________________________________Date_______

List any ailments the nurse/medical personnel should be aware of such as Heart conditions, any physical or psychological ailments. ____________________________________________________________________ Is the student currently taking medications? ____Yes _____No If “Yes”, please list medication and reason it is given and the prescribing doctor’s name And prescribing doctor’s phone number. Daily Medication(s): List Dosage and Time to be Taken

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Reason___________________________________________________________ Prescribing Doctor Name and Phone____________________________________ TRIP PROCEDURE FOR EMERGENCY CARE OR CRITICAL ILLNESS: (1) First Aid Treatment, (2) Notification of Parent/Guardian, (3) Emergency Medical Transport fo Hospital Emergency Room. The recommendation of the Parent/Guardian, as indicated above, will be respected as much as is possible. If unable to contact Parent/Guardian, permission is hereby granted to arrange for transportation and emergency hospital care. It is understood that in the final disposition of an emergency, the judgment of the Nurse and Medical Personnel will prevail. If at any time the above information must be changed, the Parent/Guardian hereby agrees to notify the Choral Director and/or Nurse. We the undersigned (below) have read and agree to abide by all rules set forth by the Director. The Parent/Guardian grants permission for their son or daughter to participate in the trip and will not hold the Director or Staff responsible for any unforeseen accident, illness or loss of property during or in transit to/from the trip.

Signature of Parent/Guardian ________________________________Date___________ Signature of Student_______________________________________ Date___________ Signature of Director_______________________________________Date___________


Choral Trip Health/Medical Release Form  

Students must fill out this form before they are permitted to go on a choral trip.

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