Microsoft word - medical_form_13-14

Tabb Tiger Band 2013-2014
Consolidated Medical Form
Student Name _______________________________________________ Home Address ______________________________________________________________________________________ Home Phone # ______________________ Primary Doctor with Phone #: ______________________________________ Food/Drug Al ergies: NONE KNOWN OR YES, as noted here ________________________________________ NONE KNOWN OR YES, as noted here ________________________________________ Current Medications: _________________________________________________________________________________ __________________________________________________________________________________________________ Insurance Carrier _______________________________Policy ID # and Sponsor Name____________________________ Every effort will be made to contact the parents in the event of Parent/Guardian and Emergency Contact Information
any serious injury or illness to their child. Please print clearly! Father’s Name (or Guardian) ______________________________________________ Home Phone # _______________ Work Phone # _______________ Cel Phone # __________________ Mother’s Name (or Guardian) _____________________________________________ Home Phone # _______________ Work Phone # _______________ Cel Phone # __________________ Additional Emergency Contact Name _______________________________________ Phone # _________________ Additional Emergency Contact Name _______________________________________ Phone # _________________ Student Medications
NO STUDENT MAY CARRY HIS or HER OWN MEDICATION. This applies to both prescription AND over-the-counter
medications. If your child needs to bring medication on a trip, it must be given to the designated chaperone for safekeeping, or in
the case of inhalers and epi-pens, the chaperone needs to be notified of any use and backups should be held by them for
emergencies. Please provide only the amount of medication needed for a specific trip in a PHARMACY-LABELED CONTAINER.
The following over-the-counter medications are carried by a designated parent chaperone to dispense to Band members on
an emergency basis—according to the dosages stated below—whenever the Band travels to footbal games, competitions,
and on any other scheduled Band trips. It is very important that you review the list of medications below, and cross out
any medications that your child is not authorized to receive. No other medications are carried in the Band’s first aid kit.
Imodium AD (Loperarnide HCL) anti-diarrhea Excedrin Migraine (250mg acetaminophen + 2 geltabs with water, only once in 24 hrs Bismuth subsalicylate (generic Pepto Bismol) Sudafed PE (phenylephrine HCI) decongestant Diphenhydramine HCI (Benadryl) antihistamine Acetaminophen (Tylenol and generic Tylenol) Zinc Oxide Cream, Lanacane and Solarcaine sprays 50mg/1-2 tablets every 4-6 hours, up to 8 in 24hrs
Medical Release Authorization
I hereby authorize emergency medical treatment to be administered to the above-named student while traveling or performing with the Tabb HS Band. The student is covered by the identified company and policy, and I agree to pay any additional medical or transportation expenses that arise from any emergency, whether medical or behavioral. I give my permission to the designated Band chaperone to dispense medications in accordance with policy stated above. ____________________________________ ____________________________________ _______________

Source: http://s136670935.onlinehome.us/documents/Forms/Medical_Form_13-14.pdf