Form for emergency medical treatment

LAST NAME
EMERGENCY MEDICAL TREATMENT & CONSENT FORM Parent’s or guardian’s medical authorization for student’s participating in and traveling with the Niceville High School Band. This authorization is good for entire school year, from July 2010 through July 2011 (or graduation). · Part I—Student’s Personal and Family Information
Person to call if parents not available: History of: Asthma -----------------  Diabetes --------------- 
Head Injury ------------  Heart trouble ----------  Hemophilia ------------  Kidney trouble --------  Rheumatic Fever ------  Is the student on a long-term medical program? --------------------- Year of Last Tetanus Booster (if known) Immunizations Current? --------------------------- Important: On the back, list past surgical history and current medications (prescription and over-the-counter). --------------------------- May the student be given the following over-the-counter medications by band staff or chaperones?
Tylenol (acetaminophen) -------------------------------- --------------------------------------------------- N Pepto Bismol -------------------------------- Advil (ibuprofen) -------------------------------- E ------------------------------------------------- N Tums -------------------------------------------------------- Note: Any medication brought by the student for administering at a band function must be clearly labeled with the student’s name, dosage, and
time to be given. Medication will be held by the band director, staff, or designated chaperone during the band function.
· Part IV—Activity and Treatment Limitations
Permission to participate in band overnight trips -------------------------- Y N As parent or guardian, I consent to the medical Permission to participate in band water activities ------------------------- Y admission of the student named in Part I and to such general and or acute nursing care, medication, Permission for emergency medical treatment of student by EMS medical diagnostic tests, blood products, and other personnel, physician, or hospital emergency room staff. (If no, general care determined to be necessary by the explain below.) ------------------------------------------------------------------ Y attending physician, except as described in Part IV. Limitations of medical treatment beyond those given in Part III: This consent applies to the use of emergency life saving procedures should such procedures prove necessary. This consent allows for designated Band Chaperones access to this form for medical needs medications in circumstances where advanced Note: If the student has any contagious disease, serious illness, or recent
accidents, or if any of the above medical information changes, please notify the chaperone or band staff traveling with the band. Signature
STATE OF FLORIDA, COUNTY OF OKALOOSA
This instrument was acknowledged before me this ____day of__________________ 20___ (date) by __________________________________________________________ (name), who is personally known to me or who has produced ______________________________ (Type of identification) and who did/did not take an oath.
_________________________________________________ NOTARY PUBLIC

Source: http://www.okaloosa.k12.fl.us/niceville/band/Forms/2009-10/Medical%20Form.pdf