Meridian World School - Medical and Insurance Information And
Meridian World School - Medical and Insurance Information and
Parent Consent for Student Travel and Medical Treatment
Student Name ______
Home Address ______Phone ______
Parent/Guardian ______Phone ______
Parent/Guardian ______Phone ______
MEDICAL INFORMATION (use back of page if necessary)
List known allergies (food, medications, etc.) If none, state “none”: ______
______
List medical history (serious illness/allergic reactions, seizures, surgeries, etc.). If none, state “none”:______
______
List over-the-counter medication(s) the student is presently taking and the purpose. If none, state “none”:
______
List prescription medication(s) the student is currently taking and the purpose. If none, state “none”: ____
______
Will student need to take medicine on this trip? ___ No ___ Yes (If yes, please fill out chart below)
Please list all medications (over-the-counter AND prescription) THAT WILL BE TAKEN ON THIS TRIP. These medications must be delivered to Kathy Ilgen (or other designated staff member) in the original packaging, in a sealed Ziploc bag, labeled with the student’s name. Students who are authorized to self-carry meds at school (e.g. Epi Pen, inhaler) will be permitted to self-carry on the trip, but please list those medications below.Name of Medicine: / Purpose of Medicine: / Is this medicine mandatory, or to be taken only as needed? / Dosage Amount/Time of Day Instructions:
(if self-carry/administer, please say “self-carry/administer”)
__ mandatory
__ as needed
__ mandatory
__ as needed
__ mandatory
__ as needed
__ mandatory
__ as needed
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MEDICAL INSURANCE INFORMATION
Medical Insurance Company ______Ins. Co. Phone #______
Policy # ______Group/Plan # ______
Current Physician ______Phone ______
____ Please check here to indicate that you have attached a copy of medical insurance identification card.
CONSENT FOR TRAVEL AND FOR MEDICAL TREATMENT
I, undersigned, being the parent or the legal guardian of ______,
(Student Name)
with date of birth ______, hereby grant permission for the above named student to travel to
(MM/DD/Year)
Ecuador from March 11-18, 2017 and hereby grant authorization to Charles Ryder, Stela Holcombe and/or Mark Rogers to obtain any emergency medical and/or surgical treatment and procedures from a physician or hospital emergency room physician on behalf of the above named student, as well as grant permission to administer medication as indicated by physician.
______
Printed Name of Person Giving Consent Signature
______
Relationship to student Phone Number
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