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Emergency information

Student Name ____________________ School/Team ____________________ REGISTRATION/EMERGENCY INFORMATION FORM
Required for ALL students at High Trails:
• Completion of EMERGENCY INFORMATION FORM
• Parent/Legal Guardian signature for AUTHORIZATION FOR EMERGENCY TREATMENT
• Parent/Guardian signature PART A: AUTHORIZATION FOR OVER-THE-COUNTER MEDICATION
Complete PARTS B, C, and D if students will bring any medication to High Trails (pages 3 and 4).
Please fill in all blanks with relevant information or indicate Not/Applicable (N/A). Name (last, first)____________________________________________________ Date of Birth ______________________ Parent Name________________________________________________________ Home Phone______________________ Parent Address_______________________________ Dad Work Phone________________ Dad Cell ________________ _______________________________ Mom Work Phone_______________ Mom Cell _______________ Emergency Contact (if the above can’t be reached) ____________________________________ Relationship __________________ Home Phone ___________________ Cell Phone________________________ Work Phone ______________________ Health Concerns: Circle and explain.
Has your child been treated for any communicable disease in the past three weeks? (yes/no) If so, what? _________

Does your child have any of the following health and/or diet concerns?
Asthma?
(yes/no) Explain ________________________________________________________________ Inhaler?
(yes/no) What type? (rescue, preventative)____________________________________________ Drug Reactions?
(yes/no) Is so, to what? ___________________________________________________________ Allergies?
(yes/no) If so, to what? ___________________________________________________________ Epi-Pen? (yes/no) For what specific allergin? ___
_______________________________________________ Diabetes?
(yes/no) Explain __________________ _______________________________________________ Operations?
(yes/no) Explain __________________ _______________________________________________ Dietary Restrictions? (yes/no) Explain _________________________________________________________________
Serious illness?
(yes/no) Explain _________________________________________________________________ Student’s Doctor_____________________________________ _______________ Doctor’s Phone_____________________ Medical Insurance? (yes/no) Name of plan_______________________________ Policy/Group# ____________________ AUTHORIZATION FOR EMERGENCY TREATMENT
In the event I cannot be reached in an emergency, I hereby give permission to the licensed medical provider selected by the director of High Trails and the teacher/administrator in charge from my school to secure and administer treatment, including hospitalization, for the person named above. I understand that reasonable attempts will be made to notify me regarding any illness or accident requiring off-site treatment. I authorize High Trails staff and/or school personnel to transport my child to medical care. ______________________________ Student Name ______________________ School/Team ______________________ AUTHORIZATION FOR OVER-THE-COUNTER MEDICATIONS
If your child develops a need for over-the-counter medications during his/her stay at High Trails, some medications are stocked in the High Trails Health Center. The High Trails nurse will assess a need and administer these medications for symptomatic relief. The over-the-counter medications (or the generic equivalent) at the Health Center include: Acetaminophen/Caffeine/Pyrilamine Maleate (Midol) ƒ Antacid (Mylanta/Tums) ƒ Insect repellent (containing DEET) ____ I give permission for the nurse at High Trails Outdoor Education Center to give
my child, _________________________________, over-the-counter medications except for
____________________________________ to provide symptomatic relief of the condition.
____ I do not give permission for my child, _________________________________, to receive
________________________________________________ ___________________________ Parent/Legal

Source: http://atomicfx.org/pipermail/d13_atomicfx.org/attachments/20110902/18d78958/attachment.pdf