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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)
Antacid (Mylanta/Tums) 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 notgive permission for my child, _________________________________, to receive
________________________________________________ ___________________________ Parent/Legal
Head lice are a constant problem in our region. Pre-school and school children are most susceptible to infestation but adults can be affected too. Exaggerated personal hygiene or preventative measures are no protection. Important aspects are:Look careful y and be aware of the risk of infestationIf the worst comes to the worst act responsibly and reasonablyLice are mainly spread by head to head