Student Name ____________________ School/Team ____________________REGISTRATION/EMERGENCY INFORMATION FORM Required for ALL students at High Trails:
• Completion of EMERGENCY INFORMATION FORM
• Parent/Legal Guardian signature for AUTHORIZATION FOR EMERGENCY TREATMENT
• Parent/Guardian signature PART A: AUTHORIZATION FOR OVER-THE-COUNTER MEDICATION 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? Asthma?
(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)
Antacid (Mylanta/Tums) 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 notgive permission for my child, _________________________________, to receive
________________________________________________ ___________________________ Parent/Legal
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
Student Name ____________________ School/Team ____________________
REGISTRATION/EMERGENCY INFORMATION FORM 
Student Name ______________________ School/Team ______________________
AUTHORIZATION FOR OVER-THE-COUNTER MEDICATIONS