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Microsoft word - ctd cli 08 health form.doc
Civic Leadership Institute 2008
Civic Education Project
Center for Talent Development
Health Information Form
For signature by student AND parent/guardian
EMERGENCY CONTACT INFORMATION
*A person other than a parent/guardian who will be available to contact during the course of the program
PHYSICIAN & INSURANCE INFORMATION
*Please bring health insurance and pharmacy cards (or copies of both sides) to the program
Please check any of the following that apply to you: ❑ Allergies/Sinus Infections
❑ Vision/Hearing Impairment ❑ Other (Explain below)
Please provide more information on any of the above, or describe other physical or psychological conditions or disabilities of which Civic Leadership Institute staff should be aware (use attached sheet if necessary)
Please list any special dietary needs (e.g. vegetarian, vegan, etc.):
Please list any allergies or adverse reactions to medications, food, insects, etc.:
(Please See Reverse)
All medications that students bring to the program must be turned in to CTD staff for storage. CTD staff will NOT administer any prescription medications to students. Students are solely responsible for remembering to take their medications according to the prescribed schedule, and must check in at the Site Office to self-administer their medication in the presence of CTD staff. If your student will need the help of a Civic Leadership Institute staff member for a prescribed medication, please contact our office prior to the program to discuss details. Medication
NONPRESCRIPTION MEDICATION RELEASE
The Civic Leadership Institute Site Office will have basic first aid supplies and over-the-counter medications accessible at all times. In the event of any minor health problems students may incur during the program, Civic Leadership Institute staff will administer the following over-the-counter medications (or their generic equivalents) for the symptoms indicated. Please initial all medications that our staff MAY administer to your student on an as-needed basis.
Tylenol for pain or headache Ibuprofen for pain, headache, or menstrual cramps Tums or Rolaids for upset stomach Pepto-Bismol for upset stomach Sudafed PE (phenylephrine and acetaminophen) for sinus congestion Benadryl for allergy symptoms Halls cough drops for cough Robitussin for cough Band-aids, antiseptic wipes, Neosporin, gauze, latex gloves for cuts or scrapes Please note any allergies to common medications or first aid supplies:
PERMISSION TO TREAT
While participating in the Civic Leadership Institute, a program of Northwestern
University’s Center for Talent Development, if a student needs any type of medical
treatment, the signature(s) below constitute necessary permission to obtain such treatment.
It should be understood that students may be transported to area hospitals or medical
facilities for diagnosis and treatment. Any and all related expenses will be the responsibility
of the student and/or parent or guardian.
I certify that the foregoing information is true and complete to the best of my knowledge. To
ensure the safety of each student, I understand that the information I am providing will be
available to appropriate Center for Talent Development staff and medical professionals
working with this student, to utilize with discretion. I give my permission to Center for Talent
Development staff to seek medical care for my son/daughter who is under the age of 18.
Signature of Parent or Legal Guardian
Civic Education Project
• Center for Talent Development
Northwestern University • 617 Dartmouth Place • Evanston IL 60208 • 847-467-2572 • email@example.com
DAVID A. YEAGER, DPM, FASPS, FACFAS Practice Information: KSB Foot and Ankle Center/ Wound Care Center Dixon, IL 61021 Residency Director of KSB Hospital; Podiatric Medicine and Surgery Residency with Reconstructive Rearfoot/Ankle Surgery Clinical Assistant Professor in the Department of Family and Community Medicine at the University of Illinois College of Medicine at Rockford C
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