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Emergency information

Student Name ____________________ School/Team ____________________ REGISTRATION/EMERGENCY INFORMATION FORM
Required for ALL students at High Trails:
Complete PARTS B, C, and D if students will bring any medication to High Trails (pages 3 and 4).
Please fill in all blanks with relevant information or indicate Not/Applicable (N/A). Name (last, first)____________________________________________________ Date of Birth ______________________ Parent Name________________________________________________________ Home Phone______________________ Parent Address_______________________________ Dad Work Phone________________ Dad Cell ________________ _______________________________ Mom Work Phone_______________ Mom Cell _______________ Emergency Contact (if the above can’t be reached) ____________________________________ Relationship __________________ Home Phone ___________________ Cell Phone________________________ Work Phone ______________________ Health Concerns: Circle and explain.
Has your child been treated for any communicable disease in the past three weeks? (yes/no) If so, what? _________

Does your child have any of the following health and/or diet concerns?
(yes/no) Explain ________________________________________________________________ Inhaler?
(yes/no) What type? (rescue, preventative)____________________________________________ Drug Reactions?
(yes/no) Is so, to what? ___________________________________________________________ Allergies?
(yes/no) If so, to what? ___________________________________________________________ Epi-Pen? (yes/no) For what specific allergin? ___
_______________________________________________ Diabetes?
(yes/no) Explain __________________ _______________________________________________ Operations?
(yes/no) Explain __________________ _______________________________________________ Dietary Restrictions? (yes/no) Explain _________________________________________________________________
Serious illness?
(yes/no) Explain _________________________________________________________________ Student’s Doctor_____________________________________ _______________ Doctor’s Phone_____________________ Medical Insurance? (yes/no) Name of plan_______________________________ Policy/Group# ____________________ AUTHORIZATION FOR EMERGENCY TREATMENT
In the event I cannot be reached in an emergency, I hereby give permission to the licensed medical provider selected by the director of High Trails and the teacher/administrator in charge from my school to secure and administer treatment, including hospitalization, for the person named above. I understand that reasonable attempts will be made to notify me regarding any illness or accident requiring off-site treatment. I authorize High Trails staff and/or school personnel to transport my child to medical care. ______________________________ Student Name ______________________ School/Team ______________________ AUTHORIZATION FOR OVER-THE-COUNTER MEDICATIONS
If your child develops a need for over-the-counter medications during his/her stay at High Trails, some medications are stocked in the High Trails Health Center. The High Trails nurse will assess a need and administer these medications for symptomatic relief. The over-the-counter medications (or the generic equivalent) at the Health Center include: Acetaminophen/Caffeine/Pyrilamine Maleate (Midol) ƒ Antacid (Mylanta/Tums) ƒ Insect repellent (containing DEET) ____ I give permission for the nurse at High Trails Outdoor Education Center to give
my child, _________________________________, over-the-counter medications except for
____________________________________ to provide symptomatic relief of the condition.
____ I do not give permission for my child, _________________________________, to receive
________________________________________________ ___________________________ Parent/Legal


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THE 2004 PROHIBITED INTERNATIONAL STANDARD (update 25 November 2003) This List shall come into effect on January 1st 2004. THE 2004 PROHIBITED LIST WORLD ANTI-DOPING CODE Valid 1st January 2004 (Updated 25 November 2003) SUBSTANCES AND METHODS PROHIBITED IN-COMPETITION PROHIBITED SUBSTANCES S1. STIMULANTS The following stimulants are prohi

Summer Games 2013 CAMPER HEALTH HISTORY AND AUTHORIZATION This form is MANDATORY and must be completed by the legal guardian of all persons (child and adult) attending Summer Games. This form is REQUIRED at the time of camper check-in and the “Camp Authorization” (back page) MUST BE SIGNED . Completed Name of Participant :_____________________________________ Birth d

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