Please make additions and changes and return by july 15, 2005

2013-2014 EMERGENCY CARE, OTC, MEDICAL PERMISSION FORM K-Grade 12

DUE MAY 1, 2013 Please complete both pages.
STUDENT AND PARENT/GUARDIAN CONTACT INFORMATION
Student Name_____________________________________________ Grade ____ Age _____ Birthdate ___________


Address ________________________________________________________________ Phone__________________
Street City State
Parent/Guardian ____________________________________________
Relationship to student _________________________________ Name of Employer ___________________________________________
Parent/Guardian _____________________________________________
Relationship to student _________________________________ Name of Employer ___________________________________________
ADDITIONAL EMERGENCY CONTACTS
List TWO contact people if parent/guardian cannot be reached in an emergency. They must be able to drive.
1. Name ______________________________________ Relationship _____________ Phone __________________
2. Name ______________________________________ Relationship _____________ Phone __________________

INSURANCE INFORMATION
Medical Plan/Insurance Company _________________________________ Policy Holder ___________________
Policy # ______________________________________
Group # ____________________________________
OVER-THE-COUNTER MEDICATION PERMISSION
Over-the-counter medications approved by the consulting physician may be administered by the school nurse, or her designee, as necessary. These medications will be given according to packaging directions appropriate for weight and age. Acetaminophen 325 mg 1-2 tablets, every 4 hours Dramamine tablets (for motion sickness, only used on school Acetaminophen 80-160 mg 1-2 chewable tablets, every 4 hours Advil (children’s oral suspension) 100mg/teaspoon, every 6 hours Hydrocortisone cream ½% or 1% for rash, itching Imodium AD according to directions for age x 1 dose Advil 200mg 1-2 tablets for pain relief or dysmenorrhea, every 4 Anbesol liquid for mouth pain, apply as directed Benadryl 12.5 mg chewable tablets or 12.5 mg/teaspoon, every 6 Robitussin DM cough syrup 1-2 teaspoons every 4 hours Benadryl 25-50 mg every 4 hours for allergic reaction Therapeutic Mineral Ice or Icy Hot pain relieving gel Benadryl gel or Caladryl lotion for insect bites □ I give my consent for my child to receive the above medications at Hathaway Brown School or on school field trips, if
deemed necessary by the school nurse or her designee. □ I DO NOT want my child to receive any medication at school.
Signature of Parent/Guardian ______________________________________ Student Name_____________________________________________ Grade ____

MEDICAL INFORMATION
Allergy Information:
 No known allergies  My child has known allergies: __________________________________________________________________ Other facts concerning the child's medical history including medications being taken and any physical impairments:
________________________________________________________________________________________________
________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

MEDICAL PERMISSION Complete either Part 1 or Part 2

PART 1: TO GRANT CONSENT
I hereby give consent for the following medical care providers and local hospital to be called: Physician ___________________________________________________ Phone _________________________ Dentist _____________________________________________________ Phone _________________________ Medical Specialist ____________________________________________ Phone _________________________ Local Hospital ______________________________________ Emergency Room Phone ____________________ In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctors, 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 authorization does not cover major surgery unless the medical opinions of two (2) licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Signature of Parent/Guardian ______________________________________

PART 2: REFUSAL OF CONSENT – do not complete Part 2 if you completed Part 1.
I/we do not give consent for emergency medical treatment of my/our child. This refusal covers major medical surgery unless
the medical judgments of two licensed physicians or dentists, concurring in the necessity of such surgery, are reasonably
able to be obtained prior to the performance of such surgery. I/we acknowledge full responsibility for such refusal, and
hereby forever waive, release, discharge and hold harmless Hathaway Brown School, and its employed or contracted
personnel, from any and all claims, causes of action, responsibilities, damages or liabilities for failing to provide or arrange
for such treatment. NOTICE: NOTWITHSTANDING THE FOREGOING, I/WE ACKNOWLEDGE AND AGREE THAT IN
THE EVENT OF AN EMERGENCY OR OTHER URGENT MEDICAL CONDITION, HATHAWAY BROWN SCHOOL WILL
MAKE EVERY REASONABLE EFFORT TO CONTACT THE PARENT/GUARDIAN(S) LISTED ABOVE AND, IF
UNAVAILABLE, THE TWO PERSONS LISTED ABOVE AS “ADDITIONAL EMERGENCY CONTACTS,” BUT IF
HATHAWAY BROWN SCHOOL IS UNABLE TO ESTABLISH CLEAR, REASONABLE COMMUNICATIONS WITH SUCH
PERSON(S), EMERGENCY MEDICAL AID OR TREATMENT WILL BE PROVIDED TO THE CHILD.
Signature of Parent/Guardian __________________________________________
Please mail by May 1, 2013 to Hathaway Brown School, 19600 N. Park Blvd., Shaker Heights, OH 44122 Attn: Jody Duecker

Source: http://www.hb.edu/uploaded/Portals/All_School/Resources/Athletics/EmergencyCareFormK12_1314.pdf