Extended travel permission & medical form - student

Please complete both sides
Student’s Name _________________________________________ Date__________________ Name as printed on passport (exact spelling):_________________________________________ Student’s Age _________ Student’s Date of Birth ___________________________________ Class/Club/Team Traveling ______________________________________________________ Destination ___________________________________________________________________ Departure and Return Dates ______________________________________________________ MEDICAL/EMERGENCY CONTACT INFORMATION
________________________________________________________ ________________________________________________________ Contact persons if parent/guardian(s) cannot be reached (please list 2 people):
Name____________________________Address_____________________________________ Name_____________________________Address____________________________________ (over)
MEDICATION(S) student will be traveling with:
All prescription medication (with the exception of inhalers and EpiPens) will be collected prior to departure. Medication should be carried in the container in which it was dispensed, including the drug’s name and the prescribing physician’s name. Note any special storage requirements (e.g., refrigeration). All medication will be held, dispensed and administered under the supervision of a chaperone or administrative staff member. Medication ____________________________Reason ______________________________ Medication ____________________________Reason ______________________________ Medication ____________________________Reason ______________________________ May the student be given the following over-the-counter medications if needed?
Loperamide (Imodium)
Dimenhydrinate (Dramamine)
Ibuprofen (Advil/Motrin)
Antacid (Tums, Mylanta)
Does the student have ALLERGIES or health concerns that chaperones should be aware of?
Please be specific.

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are there any other drugs (prescription or nonprescription) that should NOT be administered?
If so, please list.
_____________________________________________________________________________ Has the student had any medical problems or illnesses during the last year? If so, please list.
_____________________________________________________________________________ _____________________________________________________________________________ Date of Last Tetanus Shot (Must be within the past 5 years) ____________________________ Physician __________________________________ Phone ____________________________ Dentist ____________________________________ Phone ____________________________ Medical Insurance Company _____________________________________________________ Policy Number ________________________________________________________________ In case of an emergency, every effort will be made to contact you or the persons that were listed as the emergency contacts. However, if that is not successful, it is important that you grant permission for a licensed physician or accredited hospital and their associates to perform any medical/surgical procedures that are deemed necessary for the treatment of the named individual. In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by a licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. Signature of Student________________________________________ Date______________________ Signature of Parent ________________________________________ Date _____________________

Source: http://old.shaker.org/ChoirOrchestraTour2011/documents/STUDENTPERMISSION-MEDICALFORM.pdf


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