Iosco PRIDE

Iosco PRIDE Information, Release, and Medical Form

2012-2013

 

My son/daughter ______________________________________ has my permission to accompany the Iosco PRIDE Team to all PRIDE performances and activities during the 2012-2013 school year including PRIDE camp June 12-15, 2012.

 

Medical Information

 

PRIDE Member’s Name ___________________________________________________

 

PRIDE Member’s Birth Date ___________________________

 

Check the school the Member attends:  Tawas___ Hale___ Oscoda___ W-P___ Other___

 

Parent’s Name ___________________________________________________________

 

Street Address or Mailing Address ___________________________________________

 

City_________________________________Zipcode____________________________

 

Home Phone __________________________Cell Phone _________________________

 

Parent’s Employer ________________________________________________________

 

Phone to contact you at work________________________________________________

 

Parent’s email address ____________________________________________________

 

Do you, as a parent, have Facebook or have access to Facebook?  Yes____   No _____

 

If unable to contact parents, contact:

 

Name __________________________________________ Phone __________________

 

Your Doctor’s Name ______________________________ Phone __________________

 

Doctor’s Address _________________________________________________________

 

City _____________________________   Zip code______________________________

 

Insurance Information

 

Insurance Company _______________________________________________________

 

Policy Number ___________________________________________________________

The following basic medical information is necessary for your protection during our travels:

 

I am allergic to:  (check all appropriate)

• Bee stings                              
• Wasp stings
• Egg products
• Milk products
• Peanuts
• Other foods ___________________________________________________

 

I am allergic to the following medications:

• Aspirin
• Motrin
• Penicillin
• Sulfa
• Other ______________________________________________________

 

I am subject to:  (check all that apply)

• Frequent headaches
• Fainting
• Sleep walking
• High blood pressure
• Heart condition
• Diabetes
• Asthma
• Other _________________________________________________________

 

Medication taken for the above conditions:  (please include both over-the counter medications taken regularly along with prescribed medications)

 

 

 

 

 

 

I received my last tetanus shot _________________________ (date)

 

Other medical information my doctor or parents feel should be known:

 

 

 

Medical Treatment Release

If the parents and/or authorized physician named cannot be reached at the time of an emergency and if immediate observation or treatment is urgent in the judgment of Jeanne Hamilton, Jennifer Pintar, Michael Miszak, or Lyle Groff, I authorize and direct them or an authorized chaperone to send my child, ______________________________, (properly accompanied) to the hospital and/or doctor most easily accessible for such treatment.  I agree to reimburse the Iosco PRIDE Team for any medical costs that might be incurred by my child while on the trip. 

 

Parent’s Signature ____________________________________ Date ________________