Medical Information Dowling Catholic High School Instrumental Music Department Student name: ___________________________________ Grade: _________ Birth date: ________________ Address: ________________________________________ Home phone: ______________________________ Parent/Guardian: ________________________________ Work phone: ___________ Cell phone: _________ Parent/Guardian: ________________________________ Work phone: ___________ Cell phone: __________ Relative other than those listed above or an emergency contact: Name: ________________________________ Relationship: _____________ Phone: ______________________ Personal physician: _____________________________________ Phone: _______________________________ Personal dentist: ________________________________________ Phone ______________________________ Insurance information Health Insurance: ___________________________________ Policy # ________________________________ Policy holder: _______________________________________ Policy holder birth date: __________________ Medical History Past or present major disease, serious illness, or injury? No___ Yes___ (specify below) Illness, disease, injury: _________________________________________________________ Year: ________ ____Allergy (specify) ______ Contact Lenses ______Kidney Problems Food__________________ ______ Dental problems _______ Seizures Medication_____________ ______ Diabetes _______ Sleep walking Environmental: _________ ______ Fainting _______ Headaches ____ Asthma ______ Heart condition _______ Surgery ____ Bleeding disorder ______ High blood pressure _______ Other Explain items checked: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Any condition that may require special care, education, or diet: ___________________________________________________________________________________________ ___________________________________________________________________________________________
Please return this form by July 15, 2010 ________________________________ (Student’s Name) Release If parents and authorized physician or dentist cannot be reached at the time of emergency and if immediate treatment is urgent in the perception of school authorities, I request, authorize, and will be responsible for necessary emergency medical care. Our physician or dentist may be contacted and is authorized to release requested information. I understand that the chaperones will endeavor to safeguard the health and safety of each student but will, in no way, be held responsible in case of accident or illness. _________________ __________________________________________________________ Parent/Guardian (Must be signed) Over-the-counter Medications Please note, we cannot be responsible for medications given to your student by another student. I authorize chaperones to administer over-the-counter medications as directed in the event of a minor illness (e.g., Tylenol, Ibuprofen, Imodium, Dramamine, Benadryl, cold medications or, Antacids). Yes__________ No_______ Exceptions______________________________________________________________________
_________ _________________________________________________________ Parent/Guardian (Must be signed) Authorization to Administer Medication This must be signed by a parent/guardian to authorize administration of any medication being sent for the student. Medications must be in original labeled containers. Students will be allowed to self-administer asthma inhalers and eye medications. List all medications and non-prescription items such as vitamins and herbal supplements:
Medication No. of doses/day No. of Days _________ _________ ______________ ___________ ________ _________ _________ ______________ ___________ ________ _________ _________ ______________ ___________ ________ I request the prescribed medication to be administered according to the above written directions. ________________ __________________________________________________________ Parent/Guardian Please return this form by July 15, 2010
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