PENN HILLS HIGH SCHOOL MUSIC DEPARTMENT Medical Information/Emergency Treatment Authorization Student Name______________________________________ Date:__________________ Sex_____ Age _____ Date of Birth _________________ Grade: __________________ Home Address_____________________________________________________________ (Street) (City, State) (Zip) Home Phone_____________________ Parent/Guardian Cell Phone_________________ Parent/Guardian Cell Phone_________________
Parent/Guardian Name______________________________________________________ Work Phone________________________ Work Hours___________________ Parent/Guardian Name______________________________________________________ Work Phone_________________________ Work Hours___________________ Health Insurance___________________________ Subscriber_______________________ Address_______________________________ Employer________________________ _______________________________ Address_________________________ Agreement #___________________________ _________________________ Primary Care Physician_________________________ Phone_______________________ If the Band Director or Staff cannot contact either parent/guardian, please list two relatives or friends who would have authority to advise regarding your child:
If EMERGENCY TREATMENT is required, may the Band Director or Staff use their own judgment in sending the child to the hospital or doctor most easily accessible before the parent/guardian can be reached: YES NO If NO, what should be done?___________________________________________________
Does the student have any allergies? (Please list medication, environmental and dietary Allergies) __________________________________________________________________ List any medical conditions of which the Band Director or medical personnel should be made aware (i.e. asthma, diabetes, seizures, heart conditions, mental health conditions, etc.):_______________________________________________________________________ ___________________________________________________________________________ Current Medications (please list name, dose and frequency of medication) ____________ __________________________________________________________________________________ __________________________________________________________________________________
Date of Last Tetanus Shot: ______________________________________ MEDICATION WILL NOT BE DISPENSED TO ANY STUDENT WITHOUT PERMISSION FROM THE PARENT/GUARDIAN. Please review the following list of over the counter medication and circle those medications that you will allow your student to receive from the Band Director/Staff/Chaperones: Tylenol Ibuprofen Dramamine Antacids __ I DO NOT WANT ANY MEDICATIONS TO BE DISPENSED TO MY CHILD ALL MEDICAL INFORMATION WILL BE KEPT CONFIDENTIAL It is understood that in the final disposition of an emergency case, the judgment of the Band Director or Staff will prevail. The recommendation of the parent/guardian, as indicated above, will be respected as far as possible. If, at any time, the above information must be changed, I will notify the Band Director in writing. _________________________ __________________________________________________ Print Name Signature (Parent/Guardian) Date IF YOU ARE A RETURNING MARCHING BAND MEMBER AND YOUR PREVIOUS MEDICAL INFORMATION HAS NOT CHANGED, THIS FORM DOES NOT NEED NOTORIZED, JUST A SIGNATURE OF PARENT/GUARDIAN REQUIRED. Before me, the undersigned authority, personally appeared___________________________. known to me or sufficiently proven to me to be the person who executed the foregoing document. IN WITNESS WHEREOF, I have hereunto set my seal this _______ day of __________________, 20______. ___________________________________ My commission expires:_____________________ Notary Public
Consists of 6 nozzle and receiver sets that are color coded for quick identification of mating parts. Each color nozzle and receiver will only couple with their matching color component. This providescomplete protection against cross contamination. • Maximum flow rate of 45 gpm at 70 PSI • Working pressure rating: 200 PSI Fittings ENBL Nozzle with Plug Part # No
CHEM11041 Chemistry for the Life Sciences Assessment item 2 (weighting 10%) Due: 11th May, 2012 Please provide responses to the following questions using the Optical Mark Reader (OMR) form that will be supplied by your lecturers. You must follow the instruction that accompany the OMR form. You must attach a signed coversheet to your assessment item. The coversheet should be down