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Microsoft word - corrected medical formWhite Pines Ranch Outdoor Education Center
3581 Pines Rd, Oregon IL 61061 (815-732-7923) Fax (815-732-7924)
Emergency Medical Information
School: Fairview South School
Dates at WPR: September 11 – 13, 2013
Name of Participant_____________________Age____Birthdate______Boy/Girl
Address ________________________City ____________ State ___ Zip_____
Name of Parent(s): ______________________________________________
Phone Numbers: Home______________________ Work _______________
Place of Work_____________________________________
In Case of Emergency, Contact: 1. ________________Day Phone____________
2. __________________Day Phone___________
Date of Last Tetanus Booster Immunization: Month___________Year______
(Please label medication with name, dosage and time to be taken. All medication should be
given to teacher, school administrator or school nurse.)
Please allow my child to receive Tylenol and/or Benadryl as needed ____
Any known handicaps or allergies______________________________________
Activities that you would rather not participate in____________________________________
Accident/Medical Insurance Company ___________________ Policy # __________________
Assumption of Risk, Full Release and Indemnity
We are cognizant of some dangers of participating in this program. In
consideration for allowing the student to participate in activities and use ranch facilities,
we assume all risk, agree that no claim will be made against and do fully release Little
Sisters, Incorporated, it's officers, owners, employees and agents (the Program) for
injury, death, damages or any loss whatsoever incurred and however caused.
We hold harmless all Program providers from all claims by us, our family and
legal representatives. We assure you the student is in good condition and has no
impairment preventing safe participation in the Program. We indemnify the Program
from any loss it may incur because of our participation. We know this is a legal
agreement and will be broadly interpreted.
I hereby give permission for X-rays, suturing of lacerations and other treatment
deemed necessary by the attending physician in the Emergency Room.
I HAVE THE LEGAL AUTHORITY TO SIGN ON BEHALF OF THE CHILD AND
FAMILY. I HAVE READ THIS CAREFULLY AND UNDERSTAND IT. I KNOW THIS IS AS
FULL AND COMPLETE A RELEASE AS IS POSSIBLE AND I HAVE SIGNED IT
PREMIER MEDICAID INTERNATIONAL(HMO) BENEFIT PACKAGE BENEFIT PACKAGE DIALYSIS HOSPITAL INPATIENT COVERED SERVICES Surgical procedures (minor to intermediate) Internal surgical appliances/such as prosthesis and External surgical appliances/such crushes,elastic stockings Blood transfusion (international blood care services) PSYCHIATRIC / BEHAVIOURAL HEALTH SERVICES Evacuati