4phnhealthformforcamp 2011b

PORT HURON AREA SCHOOL DISTRICT
MEDICAL EMERGENCY INFORMATION SHEET
PLEASE PRINT
Student's Name _____________________________________________ SS # _____________________________________ Birthdate____________________________________ Address____________________________________________________ Telephone___________________________________City_______________________________ Zip _____________________ Parent/Guardian Email _________________________Mother/Guardian_______________________ Address_______________________________ Telephone ________________Employer_____________________________ Address_______________________________ Telephone ________________Father/Guardian________________________ Address_______________________________ Telephone ________________Employer______________________________ Address_______________________________ Telephone ________________ Name(s) of Siblings:1._______________________ 2._________________________ 3.________________________ 4. ______________________ Additional phones for emergency contacts: Pager_________________ Cel Phone________________ Other _____________ Persons to be cal ed in an emergency if we are unable to contact Parent/Guardian. Port Huron Area School District wil onlv
release students to the person( s) listed below if parent/guardian is not available. Please list available contacts.
1. Name______________________________ Address _______________________Telephone ____________________
2. Name______________________________ Address _______________________Telephone ____________________
3. Name______________________________ Address _______________________Telephone ____________________
PLEASE ADD THESE PHONE NUMBERS TO YOUR CHILD'S CELLPHONE UNDER "ICE" (i.e. ICE-John Doe)
Are there any court orders regarding this child? Yes _______ No _______
MEDICAL INFORMATION
Does your child have al ergies? Yes____ No____ He/she is al ergic to: _____________________________________________What are the symptoms of al ergic reaction? __________________________________________________________________Wil your child need medical treatment for his/her al ergic reaction? Yes______ No______If yes, please specify: _____________________________________________________________________________________What medications does your child take daily? __________________________________________________________________Has your child had seizures or passing out spel s? Yes______ No_______Does your child have problems with: Eyes _____ Ears _____ Heart _____ Lungs _____ Abdomen _____If yes, list the nature of the problem and the severity ____________________________________________________________________________________________________________________________________________________________________Date of last Tetanus Immunization ________________Physician's Name __________________________________________ __________________________________________________________________________________ For your child's safety, important health information wil be shared among school personnel associated with your child. In the event of an emergency medical condition, I understand and agree that Emergency Medical Service (EMS) wil be summoned, based upon the School District's assessment of the situation. Under such circumstances, I understand that the School District wil contact me. If the emergency is such that immediate medical care is necessary, I authorize the School District to transport my child to a hospital or emergency care facility. The hospital, their agents, or a licensed physician may administer such emergency medical treatment as they deem necessary under the circumstances.
Signature of Parent or Guardian _________________________________________________ Date ___________________ Health Form for Camp 2011
Student Name ___________________________ Date of Birth _____________ Blood Type _______
Known Allergies or Sensitivities - PLEASE LIST BELOW
Latex:
If "YES", do you take precautions at home? Explain: _____________________________________________________________________________ Medications:
____________________________________________________________________________________ ____________________________________________________________________________________ Other allergies
____________________________________________________________________________________ PERSONAL MEDICAL HISTORY:
(Please answer al questions and explain YES answers.) Asthma Back Problems Blurred Vision Chicken Pox Communicable Diseases Cold sores Convulsive Disorders /EpilepsyPersistent Cough Diabetes Diphtheria Disease of Joints (Arthritis/Gout/Torn Ligaments)Fainting or Blackouts Frequent Sore Throat Frequent Urination Gal stones or Gal bladder Trouble German Measles Hay Fever Headaches /MigrainesHearing Problems Heart Murmur, Irregular Heartbeat or Heart Condition Heat Related IllnessHigh Blood Pressure Jaundice/Skin turned yel ow Kidney Stones or Other Kidney Problems Measles Motion SicknessMumps Nosebleeds Painful Joints Pneumonia Polio Rheumatic Fever Rupture/Hernia Scarlet Fever Sexual y Transmitted/Venereal Diseases Shortness of Breath with activity/without activitySickle-Cel Anemia Stomach Pains/Ulcers/GERD or Reflux disease Teeth Problems Tuberculosis Tumor/Cancer Urinary Infection Please list how to deal with the conditions below should they occur while child is at camp.
Condition #1______________________________________ Course of action _________________________________________ ________________________________________________________________________________________________________ Condition #2______________________________________ Course of action _________________________________________ ________________________________________________________________________________________________________ Condition #3______________________________________ Course of action _________________________________________ ________________________________________________________________________________________________________ Condition #4______________________________________ Course of action _________________________________________ ________________________________________________________________________________________________________ Condition #5______________________________________ Course of action _________________________________________ ________________________________________________________________________________________________________ To your knowledge, has student had contact with any person with a communicable disease in the past two weeks? This health history is correct to the best of my knowledge. The student listed has permission to engage in al instrumental music activities for the Port Huron Northern Band Camp (August 1-5, 2011) and al band and marching band related activities throughout the 2011-2012 school year unless otherwise noted on this form. If medical treatment is needed for my child, I understand I wil be notified by the camp nurse and wil also be contacted by the hospital prior to treatment. ____________________________________________________ ______ / _______ / _______ PLEASE COMPLETE THE NEXT SECTION REGARDING MEDICATIONS
PERMISSION TO ADMINISTER MEDICATION

Please list all prescription medications and times they should be taken (attach an additional page if more than four
medications are to be administered):
Medication #1_______________________________________________ Signature ____________________________________Times to be taken daily: ___________________________________________________________________________________Medication #2_______________________________________________ Signature ____________________________________Times to be taken daily: ___________________________________________________________________________________Medication #3________________________________________________Signature ___________________________________Times to be taken daily: ___________________________________________________________________________________Medication #4_______________________________________________ Signature ___________________________________Times to be taken daily: ___________________________________________________________________________________ My student has my permission to carry an inhaler Signature ____________________________________ Name inhaler medications __________________________________________________________________________________ I give permission for any chaperone to administer the above medications to my student. In
addition, the band will keep the following over-the-counter meds in stock. It is unnecessary to
send the items below with your student. Please indicate your permission to administer these as
needed by signing next to each approved medication below:

ANTACID
"MONKEY BUTT" ANTI-FRICTION POWDER List all other over-the-counter medications you have sent with your student:
O.T.C Medication #1 SUNSCREEN________________________________
AS NEEDED__________________________________________________________________________ ___________________________________________ Signature______________________________ ____________________________________________________________________________________ ___________________________________________ Signature______________________________ ____________________________________________________________________________________ ___________________________________________ Signature______________________________ ____________________________________________________________________________________ Guardian Name _______________________________ Guardian Signature ________________________

Source: http://www.phnbands.org/Archives/downloads-2/files/4PHNHealthFormforCamp%202011B.pdf