Microsoft word - greenkillmedicalform.doc

Greenkill Outdoor Environmental Education Center 2012-2013 Program Participation & Health Form
Carol Nivens RN
Berea Elementary ___ Dates of Greenkill Experience: ___June 5 - 7 ____ Male / Female (Please circle)
Greenkill Birthday! Yes / No (Please circle)

Food / Dietary Needs:
Please notify and talk with the school regarding dietary needs. The school will coordinate with Greenkill to ensure each students needs are met. Health Concerns: It is extremely important that the school be advised of any/all health care matters regarding your child. Please note here any information that will be important for the Greenkill instructional staff to be aware of in order for them to provide a safe and positive experience for your child. Limited participation: Please understand that the students will be participating in Outdoor Environmental Education program which will include some physical activities, it is important to inform school of any activities which your child should not, or might have difficulty participating in:
Has this student ever required any psychiatric counseling or hospitalization? Yes / No (Please circle)
Do you carry family medical/hospital insurance?

Emergency Authorization REQUIRED
This health history is correct so far as I know, and the person herein described has permission to engage in all
activities in the Greenkill Outdoor Environmental Education at YMCA Camping Services program except as noted above.
Permission to Treat: I hereby give permission to the medical personnel selected by the school and/or YMCA to provide
routine health care; to administer medications; to order x-rays, routine tests, treatment; to release any records
necessary for insurance purposes; and to provide or arrange necessary related transportation for me or my child. In
the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the school and/or
YMCA to secure and administer treatment, including hospitalization, for the person named above. This completed form
may be photocopied for trips out of camp.
Signature
parent/guardian:
PHYSICIAN—PLEASE FILL OUT BOTH PARTS!!
For medications to be dispensed by a NURSE the following must be completed
by the licensed health care prescriber AND signed by parent/guardian:
THIS IS FOR PRESCRIPTION MEDS AND OVER THE COUNTER MEDICATIONS!!!!
I request that my patient receive the following prescription medication(s) including OVER THE COUNTER AND
PRN MEDS:
Name of student:

Name of Medication(s) with the prescribed dosage, frequency and route of administration:
1).
3)._________________________________________________________________________________
4)._________________________________________________________________________________
Standard Over the Counter Medications—BLANKS MUST BE FILLED (“NOT AS DIRECTED”)
The following medications are available in the Health Center with parent/guardian AND physicians order. Please
select which medications below can be administered and fill in the blanks.
Licensed Physician's Signature
Initial if completed by nurse or physician's assistant I agree with the above medications and dosages to be administered to my child.

Source: http://www.vcsd.k12.ny.us/cms/lib/NY24000141/Centricity/Domain/822/GreenkillMedicalForm.pdf