S t u d e n t M e d i c a l P l a n 2 0 0 9 - 2 0 1 0 Sponsored By: Extending Eligibility To: Administered By: TELEPHONE DIRECTORY University Health Service 2145 Adelbert Road .216-368-2450 University Counseling Services Sears Bldg., Room 201 .216-368-5872 Appointments: General Clinic . 216-368-4539 Women’s Clinic. 216-368-2453 Mental Health. 216-368-2510/5872 Dear Stu
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Please do not write in this spaceCONSENT FORM
CONSENT FOR MEDICAL TREATMENT
If necessary do we have permission to give your child GIVEN NAME
Yes___ No___ Acetaminophen-Tylenol or Tempra (fever, headache, general pain) Yes___ No___ Dimenhydrinate-Gravol (nausea, vomiting) Home Address _____________________________________________________ Yes___ No___ Ibuprophen-Advil, Ibuprofen, Motrin (pain, fever, anti-inflammatory) Yes___ No___ Cough Suspensions-Benylin, Triaminic, Robitussin City ________________________ Province ________ Postal Code ___________ Yes___ No___ Antacids-Gaviscon, Maalox, Mylanta, Tums, Rolaids (upset stomach, acid reflux, heartburn) Yes___ No___ Antibiotic Creams-Polysporin (wounds, cuts, abrasions) Ontario Health Card No. ___________________________________ Initial _____ Yes___ No___ Laxatives-Milk of Magnesia (constipation) Parent’s/Guardian’s Name(s)__________________________________________ Parent’s/Guardian’s Home Phone _______________ Work __________________ CONSENT FOR FOLLOWUP
In case of illness, notify_____________________________________________
We would like to keep in touch with your child over the next year. Address ________________________________ Phone ____________________ Yes___ No___ Ruby (Mailbox Bible Club Administrator) Yes___ No___ My camper’s Bible teacher Family Physician’s Name _____________________________________________ Address __________________________________________________________ UNDERSTANDING
City ___ _____________________ Province______ Postal Code _____________ Phone Number (_______) __ _________________________________________ In case of emergency in the event that we cannot be reached for immediate consultation, I hereby give permission to the camp leadership PRESENT PHYSICAL CONDITION: Weight _________ Height ________
to hospitalize, secure proper treatment for, and to order medications, Are there any Physical Abnormalities? If so, what __________________________ anesthesia or surgery for the camper as named above. If insufficient information is given on this medical form, I give you ________________________ _________________________________________ permission to acquire the medical information from our physician. Emotional Stability of Camper: Hyperactive ___ Developmentally Challenged ____ While every precaution is taken for the safety and good health of our campers, Mill Stream Bible Camp, its directors and staff members are Emotional Problems____ Anger Management Concerns____ Other____________ hereby released from any and all liability in the event of an illness, accident or misfortune that may occur to the camper. Parents are responsible for any additional expenses that may occur above the Pediculosis (Head Lice) ___ Impetigo ___ Athlete’s Foot ___ Plantar Warts___ Other infection: ___________ _________________________________________ To the best of my knowledge, this child is in good health and by enrolling my child I give permission for involvement in all camp activities except as May this camper participate in all Camp activities, including swimming? By enrolling my child I give permission for photo/video media of my child to be used for camp promotions via printed or electronic material, If no, which activities must be avoided? _________________________________ CAMPER HEALTH
Date _________ Parent’s/Guardian’s Signature _________________________
To be completed prior to coming to Camp. Bring with you to Camp on check-in day.
MEDICATION TO BE GIVEN AT CAMP
Is this camper subject to: (Please answer YES or NO to each) Frequency
Reason for taking medication
____ Chronic Ear Infections ____ Bed Wetting ____ Severe Stomach Aches ____ Homesickness Treatment for the above condition(s): ___________________________________ _________________________________________________________________________ _________________________________________________________________________ All medications must be left with the Camp Nurse. _________________________________________________________________________ Some exemptions may be at the discretion of the Camp Nurse.
Mill Stream Bible Camp & Retreat Centre is required by law to operate with at a minimum, qualified First Aid personnel on the grounds at all times. The camp has a physician on call and volunteer nurses or first aid personnel are on the Mill Stream Bible Camp & Retreat Centre intends to provide safe and conscienceous Has the camper been exposed to the above communicable disease within the care for your child while at camp but wish to make you aware of the limitation that Mill Stream Bible Camp & Retreat Centre operates under the guidelines of the Ontario Camping Association and the Ontario Ministry of Health, and is only required to provide What disease _____________________ When ___________________________ Mill Stream Bible Camp & Retreat Centre believes that your privacy is important for you Please note: If camper has been exposed to any of these diseases, the Camp
We do not require a physician’s signature on this medical form
and therefore are not responsible for any medical examination expenses.
Please do not write in this space below
PAST HOSPITALIZATIONS AND REASONS:
Please complete consent form on reverse page
Anmeldung Büchergilde Reisen Grenzgänge - Geschichte und Geschichten in der Euregio Maas-Rhein4-tägige sozio-historische Reise mit dem Sozialwissenschaftler Dr. Herbert Rulandvom 04. bis 07. Oktober 2012 Ruth Rick-Walther TERRA ALLEGRA / Büchergildereisen Buheleite 17 D - 97340 Marktbreit Fax: 09332 591330 oder e-mail: firstname.lastname@example.org Zu Ihrer / unserer Sicherheit benötigen