Project Health Form by zdh15614

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									Project Health Form
Project Grade 7
Project Dates: September 7-10, 2009
Please complete each part of this form carefully and accurately. When medical care is needed, this
information is essential. All information will be kept confidential.

______________________________________________________________________
Student's Last Name       First Name                 Birthdate   Male/Female

______________________________________________________________________
Home Address                        Home Phone                   Work Phone

Nationality_____________


______________________________________________________________________
Insurance Company                      Insurance Number

______________________________________________________________________
Family Doctor                           Office Phone           Town/City

Name /phone number of emergency contact person in Holland (if parent cannot be reached immediately):

______________________________________________________________________

Will you be away from home during this trip?___________________

If yes, where can you be reached?__________________________________________

1. Are there any dietary restrictions?_________________________

2.   Does your child have any allergies to:
                                                Yes*            No
     Food                                       ___             ___
     Medication                                 ___             ___
     Bee or insect stings                ___            ___
     Other                                      ___             ___

     *If yes, please specify, describe symptoms and treatment or medication used:

PLEASE SEND THE MEDICATION NEEDED FOR STUDENT’S ALLERGIC REACTION!

3. A small number of medications will be carried by the nurse. Please indicate whether your
child may receive all over the counter medication. If there is any medication you DO NOT want your child
to receive please indicate in the space provided.

I, parent/guardian of______________________________________give my permission for the school
nurse to administer all over the counter medication.

Signature parent/guardian________________________________________________

My child may not receive the following:_________________________________________

         *If prescription medication for allergic reaction is needed, please send it with
                 your child, along with directions for administering it.


4. Is there medication that your child must bring to take during this trip? No_____Yes_____
   Medication:________________________________dosage________times________
   Medication:________________________________dosage________times________
   Medication:________________________________dosage________times________

All medications will be kept and administered by the nurse, with the exception of asthma inhalers
which the child may need to carry.
5. When did your child last have a Tetanus immunization?_________________________

TETANUS IMMUNIZATION MUST BE CURRENT WITHIN 10 YEARS IN ORDER TO
                  PARTICIPATE IN THE PROJECT

6. Does your child wear contact lenses? Yes_____No____

7. Does your child have any difficulties during sleep? (Sleepwalking, bedwetting, etc.)
   No_____Yes_____. If so, please explain:

______________________________________________________________________

8. Is there any additional information the staff should have concerning your child?
If so, PLEASE ELABORATE:________________________________________________

___________________________________________________________________

9. Please indicate your child's bike riding ability:
   Doesn't know how to ride____; beginner_____; steady, good rider_______; expert___

10. Please indicate your child's swimming ability:
   Doesn't know how to swim____; a beginner____; steady, fair swimmer_____; expert___

11. Please indicate your child’s horse riding ability:
    Never been on a horse____; beginner_____; steady, good rider_______; expert_____

12. As hiking/walking is a project activity, it is important for us to be aware of your child's hiking
   experience and level of endurance:
    limited endurance_______; Average endurance_________; strong endurance_________

13. Does your child have any physical limitations? No____Yes____
     Explain, including any activities he/she cannot do:
_____________________________________________________________________
                                    AUTHORIZATION FOR MEDICAL CARE

I request that my child,______________________________________________,
born__________________, be given first aid and/or emergency medical care, treatment, or anesthesia
as indicated.

The school trip nurse has my permission to act on my behalf (in case of emergency care) for the duration of
this trip.

My child is____ is / not____ allergic to PENICILLIN.

______________________________________                           __________________
Signature of parent/guardian                                         Date




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