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Student Emergency Medical Statement/Authorization
Name __________________________________________________________________________________
School
Street Address Work Home City, State Cell Zip
Grade
Age
Address_________________________________________________________________________________ Phone __________________________________________________________________________________ Residential or custodial Parent(s)/ Guardian(s) 1. Mother’s Name _________________________________________________________ Address ___________________________________________________________________________
Street Work Home City, State Zip Cell
Phone _____________________________________________________________________________ 2. Father’s Name _____________________________________________________________________ Address ___________________________________________________________________________
Street Work Home City, State Zip Cell
Phone_____________________________________________________________________________ 3. Emergency Contact Name________________________________Relationship____________________________ Address___________________________________________________________________________
Street City, State Zip
Phone_____________________________________________________________________________
CONSENT
I hereby give consent for the following medical care providers and local hospital to be called: 1. DOCTOR______________________________________________________________PHONE__________________ 2. DENTIST______________________________________________________________PHONE__________________ 3. MEDICAL SPECIALIST_________________________________________________PHONE__________________ 4. MENTAL HEALTH OR COUNSELING PROVIDER________________________ PHONE__________________ I (the undersigned) parent or legal guardian of _______________________________, do hereby give my permission for him/her to go on the Mountain Mentors program and/or activities. In the event reasonable attempts to contact me have been unsuccessful, I also authorize the sponsors to take whatever action deemed necessary for my child, in case if illness or injury. I hereby give my consent for 1) the administration of any treatment deemed necessary by above-named providers, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and 2) the transfer of the child to any hospital reasonably accessible. This does not authorize major surgery unless the medical opinions of two other licensed physicians or dentists are obtained prior to surgery and concur that that such surgery is a necessity. Facts concerning the child’s medical history including allergies, medication being taken, and any physical impairments to which a physician should be alerted are listed on page 2 of the Emergency Medical Statement. Our hospitalization and medical insurance is held by the following company: ________________________________________Policy number____________________ 1
Date_______________________ Signature of Parent/Guardian___________________________________ EMERGENCY MEDICAL STATEMENT Name of Student_________________________________________ Date____________ Age_____ Weight._______ Height_______ Check: M________ F______Optional:Birthdate ____________ Please be sure to fill this form out carefully – it is for the safety of the participant Last Tetanus toxoid inoculation date:__________________________________________ Allergies(food, medicine, insects, etc.) – Circle yes or no; if yes, what?________________________________ Diet stipulations (religious, vegetarian, lactose free, etc ) ___________________________________________ Asthma – yes or no Give approximate dates that apply Diabetes – yes or no Kidney problems – yes or no Heart problems – yes or no Epileptic – yes or no Pregnancy – yes or no Sickle Cell Anemia – yes or no Constipation - yes or no Stomach upsets ___ yes or no ________________________________________________________________ Nervous system disorder_ yes or no ___________________________________________________________ Muscle Disease disorder_ yes or no ____________________________________________________________ Bleeding/clotting disorders yes or no ___________________________________________________________ Broken bones at any time_ yes or no ____________________________________________________________ Any serious injuries or illness__________________________________________________________________ Any eye problems___________________________Wear glasses or contacts– yes or no Sleep disturbance/ walking – yes or no Any history of, or current emotional/mental health counseling or hospitalizations - circle yes or no; _if yes, explain_____________________________________________________________________________ Any medications being taken at this time? If yes, what_____________________________________________ What medications should be taken while on the trip? ______________________________________________ Dosage information_________________________________________________________________________ Activities encouraged or limited by your physician________________________________________________ Further health information that we should be aware of – circle yes or no_______________________________ _if yes, explain_____________________________________________________________________________
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