Falls City May 7– May 9, 2013 Child’s Teacher_______________________
Authorization to Attend Outdoor School I, ________________________________ give permission for my child, (Parent/ Guardian Signature)
_______
(please print name)
________ ,
to attend the Falls City Outdoor School May 7– May 9, 2013 at Canby Grove Conference Center.
Student Health History for Outdoor School (Please Print) In order for your child to attend Outdoor School, all information on this form must be completed on all pages and signed where indicated, by a parent/legal guardian. If your child’s condition changes after you submit this form, please send the information to your students’ teacher. Student’s Name: _________________________________________ Nickname: _____________________ Name of friend you would like in a cabin with your student:__________________ (It is not guaranteed your student will be with this friend)
Birth Date:_________
Sex: M or F
Adult Shirt Size: (circle one) S/M/L/XL/XXL/XXXL
Mother’s Name: ____________________________ Home Phone:________________ Work Phone:____________________ Father’s Name: _____________________________ Home Phone:________________ Work Phone:____________________ Student’s Address:______________________________________ City:___________________ Zip Code:________________ Family Doctor:________________________________ Phone:_______________________ Emergency Contact Name#1:_____________________________ Relationship:_______________ Phone:________________ Emergency Contact Name#2:_____________________________ Relationship:_______________ Phone:________________
If medication is needed at Outdoor School, the medication section of this form must be completed. ALLERGIES (*please list below) ____Asthma or other breathing problems ____Bowel/Bladder Problems ____Bedwetting ____Diabetes ____Vision/Hearing Problems
____Emotional/behavioral or learning ____Handicapping Conditions ____Hay Fever ____Heart Problems
____Physical Injuries (Recent) ____Seizure Disorder ____Skin Problems ____Sleep Walking
____Other chronic or recent illnesses or surgical procedures (Specify):________________________________________
_________________________________________________________________________________________________ *Please provide more specific information about identified health concerns including treatment, what we should know to help your child be successful at ODS, and other pertinent health information: (Attach paper as needed):____ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Are there any special dietary needs?:________________________________________________________________________ __________________________________________________________________________________________________________
Are there any emotional, behavioral or learning needs?_______________________________________________________ __________________________________________________________________________________________________________
Are there any activity restrictions? __________________________________________________________________________ __________________________________________________________________________________________________________
MEDICATION RULES Will your child need medication while attending Outdoor School? _____ Yes _____ No
All medication (prescription and over-the-counter (OTC)) Must be turned into the students’ teacher on the day of departure, and will be maintained and administered by the school’s designated teacher. Students are not allowed to carry their own medication. All medication must be in original container (prescription or over-the-counter). No medications will be accepted or given if they are sent to Outdoor School in unapproved containers (i.e., envelopes, baggies, etc.) Prescription medication must have an accurate label. This includes samples given by physician. The direction on the prescription label must match exactly what you write on the parent/guardian authorization. If the directions on the prescription label are different from what the physician is currently prescribing, written instruction is required from the physician. All medications must be listed below
PARENT/GUARDIAN AUTHORIZATION TO DESIGNATED TEACHER TO ADMINISTER MEDICATION I am requesting that my child be given or be assisted in taking: Name of Medication
Time(s) to be Given
Purpose of Medication
Special Instructions
*If Albuterol is listed please initial here for student to carry and administer. (Student must be developmentally and behaviorally able to carry and self-administer) Parent/Guardian Initial:_______
Parent /Guardian Signature:__________________________________ Date:__________________ (This authorization applies only to the medication listed above and for the duration of treatment or week. This also authorizes an exchange of information, as necessary, between appropriate school personnel, the ODS nurse, and/ or my child's health provider)
STUDENT NAME ______________________________________
TEACHER & SCHOOL__________________________
AUTHORIZATION FOR ADMINISTRATION OF OVER-THE-COUNTER MEDICATION BY THE OUTDOOR SCHOOL NURSE For the relief of minor health problems that might temporarily affect your child’s comfort while at Outdoor School, the nurse maintains a small supply of common over-the-counter medications at the site. These medications are administered, as needed, under the standing orders of the Outdoor School consulting physician. Your personal physician does not need to sign for the medications listed below. Do not send these medications with your student. If needed, our stock supply will be used. THE HEALTH HISTORY FORM IS CHECKED FOR ALLERGIES BEFORE ANY MEDICATION IS GIVEN. IF YOU WANT YOUR CHILD TO RECEIVE OVER-THE-COUNTER MEDICATION, IF NEEDED, AND AT THE DISCRETION OF THE OUTDOOR SCHOOL NURSE, YOU MUST SIGN BELOW. IF THIS LIST CONTAINS MEDICATION YOU DO NOT WANT YOUR CHILD TO RECEIVE, DRAW A LINE THROUGH THAT MEDICATION BEFORE SIGNING. Medications available for the Outdoor School Nurse to use for your child are: Kaopectate
Lotion/cream for chapped skin (Eucerin)
Non-aspirin pain/fever relievers such as Tylenol or Advil
Soap for poison oak/ivy (Tecnu)
Antihistamines (Benadryl, Chlor-Trimeton)
Cream for athlete’s foot or ringworm (Lotrimin)
Throat lozenges (Cepacol)
For burns/sunburn (Aloe Vera gel)
Cough syrup (Robitussin-DM)
Cream for itching (Hydrocortisone,Benadryl, Calamine or Caladryl lotion)
Cough drops
Vaseline
Sunscreen
Maalox Plus Tablets, Milk Magnesia
Alcohol Wipes
Glucose for diabetic emergency
Antibiotic Cream/Ointment
*Epinephrine
Insect repellant *Epinephrine is a prescription medication kept on site for use in the event of a life threatening allergic reaction, not a substitute for students who are required to carry epinephrine.
NOTE: Brand names have been listed but their generic equivalent or the same medication of a different brand may be substituted. We do not stock chewable or liquid pain relievers. Please select the boxes below of medical actions ODS medical staff and teachers are allowed to administer for your child. I authorize the Outdoor School Registered Nurse to administer over-the-counter medication (limited to those on list) under the direction of the consulting physician’s standing orders, as needed, to my child while at Outdoor School. IN CASE OF MEDICAL OR SURGICAL EMERGENCY, I hereby give permission to the physician selected by the Outdoor School Coordinator to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child, as named above. (Legal parents/guardian contacted first whenever possible.)
Parent /Guardian Signature:__________________________________ Date:__________________ By signing you authorize the above selected treatment for your child while at Outdoor School. Please return signed, completed form to your child’s teacher by April 18, 2013 for your son/daughter to attend Outdoor School. If you have any questions about this form or any aspects of the Outdoor School program/experience, please call 503-623-9680 or contact your child’s teacher.