Microsoft word - lym camper med release form 2013.doc
EMERGENCY MEDICAL RELEASE FORM 2013 Name: _______________________________________________________________________ Last First Middle Address:______________________________________________________________________ ______________________________________________________________________ Birth date: _______________________ Male: ____ Female: ____ Parents: _____________________________________________________________________ Address: _____________________________________________________________________ Home Phone: ___________________________ Work Phone: __________________________ Cellular: ________________________________ HEALTH INFORMATION General - Is Youth subject to: (If "yes" - explain) _____ Yes _____ No Fainting _____ Yes _____ No Sleep Walking _____ Yes _____ No Upset Stomach _____ Yes _____ No Other Reactions / Allergies - Is Youth subject to: (If "yes" -explain and list medication) _____ Yes _____ No Penicillin _____ Yes _____ No Other drugs _____ Yes _____ No Bee sting _____ Yes _____ No Poison Ivy, etc. _____ Yes _____ No Other allergies _____ Yes _____ No ___________ _____ Yes _____ No ___________ Medications / Conditions -Is Youth subject to: (If "yes" - explain and list medication) _____ Yes _____ No Asthma _____ Yes _____ No Bronchitis _____ Yes _____ No Diabetes _____ Yes _____ No Heart condition _____ Yes _____ No Sight / Hearing _____ Yes _____ No Wears Contacts _____ Yes _____ No Serious Illness or injury in last ten years Date of Last Tetanus Shot: _________________________ Please indicate ANYTHING else that adult leaders should know to help deal with any medical situation that may arise:__________________________________________________________ _____________________________________________________________________________ EMERGENCY INFORMATION (please include photocopy of insurance card) Health Insurance Co. _____________________________________ Policy #_______________ Family Doctor ___________________________________________Phone _________________ Other #'s______________________________________________________________________ Other Contact Person__________________ __________________ Relationship ____________ Home Phone: ___________________________Work Phone: ____________________________ Cellular: ________________________________ Page 1 of 2 AUTHORIZATION TO CONSENT TO MEDICAL AND DENTAL CARE
I, the undersigned parent and/or legal guardian of_________________________,a minor under age 18, do hereby authorize the camp nurse, Robert Milkert or an authorized adult member of Lutheran Youth Ministries to consent to: 1. Medical, surgical and dental care for such minor child; 2. Consent to any diagnostic tests, medical, surgical or dental procedure or treatment as may be considered necessary by the physician, surgeon, dentist, or other health care personnel providing care for such minor child: 3. and on my behalf to: a. employ physicians, surgeons, dentists, nurses and other health care personnel as may be deemed necessary for such minor child, b. admit such minor child to any hospital, clinic, emergency room, laboratory, or other health care or diagnostic facility for examination, treatment, surgery or care, c. sign all necessary consents and authorizations 4. any non-emergency first aid, including the administration of: ____ _ Yes _____ No Acetaminophen (Tylenol or similar pain reliever) _____ Yes _____ No Pepto Bismol / Imodium AD _____ Yes _____ No Antacid (Tums, Maalox) _____ Yes _____ No Decongestant (Sudafed) _____ Yes _____ No Benadryl It is understood that this authorization is given in advance of the occurrence of any condition or situation that would necessitate any such medical, surgical or dental care being required, but is given to provide authority to obtain such care if it should be required. This document shall be in effect for the dates of July 14, 2013 through June 30, 2014. IN WITNESS WHEREOF, I have executed this Authorization to consent to Medical and Dental Care this _______ day of _________, 2013 ___________________________________ Parent / Legal guardian ___________________________________ Parent / Legal guardian State of _______________ ________________ County On this day of ,2013, before me, a Notary Public, personally appeared and known to be the person who executed the above Consent and stated that it was executed as their free act and deed. ___________________________________ (SEAL) Notary Public Page 2 of 2
BILL ANALYSIS AUTHOR'S / SPONSOR'S STATEMENT OF INTENT The U.S. Department of Justice (DOJ) recently charged Forest Laboratories with defrauding the government of millions of dollars by illegally marketing Celexa and Lexapro for unapproved uses in children and teenagers. The DOJ complaint cited that concealed drug studies showed that the drugs were not effective in children and might
Caso AH1N1 Il Complotto Docume nti che analizzano la t eoria del compl otto LE INCHIESTE IN CORSO E L’DEA DEL COMPLOTTO INTERNAZIONALE PREMESSA La giornalista austriaca Jane Burgermeister ha presentato una serie di esposti contro la Baxter e l’OMS e l’ONU per attività illegali e criminali nella preparazione della massiccia campagna di informazione deviata sulla presu