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 not give permission for my child, _________________________________, to receive
________________________________________________ ___________________________ Parent/Legal
Source: http://atomicfx.org/pipermail/d13_atomicfx.org/attachments/20110902/18d78958/attachment.pdf
© C o py r ig h t , 1 9 9 7, by t h e Ma s s a c h u s e t t s Me d i c a l S o c i e t y V O L U M E 3 3 7 N U M B E R 1 1 A CONTROLLED TRIAL OF TWO NUCLEOSIDE ANALOGUES PLUS INDINAVIR IN PERSONS WITH HUMAN IMMUNODEFICIENCY VIRUS INFECTION AND CD4 CELL COUNTS OF 200 PER CUBIC MILLIMETER OR LESSSCOTT M. HAMMER, M.D., KATHLEEN E. SQUIRES, M.D., MICHAEL D. HUGHES, PH.D., JANET M. GRIMES, M
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