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Microsoft word - trek la emergency medical form.doc

Medical Form and Emergency Contacts
Child’s Name______________________________________ Date of Birth___________________
Address__________________________________City____________________Zip______________
Mother’s Name______________________________
Home #___________________ Work #_________________
Cell #____________________
Father’s Name_______________________________
Home #_____________________ Work #_____________________ Cell #____________________
In Case of Emergency please contact:
Name______________________Phone_________________ Relationship______________
Name______________________Phone_________________ Relationship______________
Name______________________Phone_________________ Relationship______________
Health Care Information
Insurance Provider__________________
Policy#________________________________
Phone: ___________________________________________________________________
Doctor_____________________________ Phone #_______________________________
Any additional medical information_____________________________________________
_________________________________________________________________________
Medical History
Has your child had any of the following (Please indicate the most recent dates):
Mumps__________ Measles__________ Headaches______________ Tonsillitis________ Fainting__________ Nosebleeds______________ Does your child have any condition that would prevent him/her from participating in any
activities?

__________________________________________________________________________________
__________________________________________________________________________________ Medical Form and Emergency Contact Information Trek LA Page 1 of 2 Please provide details of any of the following ailments (if applicable):
Allergies (food, drugs, etc.)____________________________________________________________ Bee Stings, Mosquitos________________________________________________________________ Asthma or Hay Fever_________________________________________________________________ Serious Injuries/Illnesses______________________________________________________________ In addition, please describe the reaction if exposed to any allergens, the severity of the reaction, and
the requested course of action:
_________________________________________________________
Does your child require an EpiPen? Yes: _______ No: ____________
Has your child received medical treatment during the past year? Yes: Date: _____________ Reason: ____________________________________________ Does your child currently take medication? ___________________________________________
If Yes, please list medications: ______________________________________________________
Will your child require any medication while at camp? Yes: ________ No: ___________ Is your child up-to-date on all state required immunizations? _________________________________ Please provide the date of your child’s last tetanus shot: ____________________________________ Please check the non-prescription medications that we have permission to give your Pepto Bismol ____ Throat lozenges _____ Tylenol ______ Benadryl ______ Dramamine ______ Advil _______ I hereby give Trek LA permission to administer medications indicated on this form and Trek LA is held harmless. Incase of an emergency and I cannot be reached, I authorize Trek LA director or her designee, to obtain medical treatment that he or she deems necessary for the welfare of my child or ward. Parent/Guardian Name____________________ Relationship _________________
_______________
Medical Form and Emergency Contact Information Trek LA Page 2 of 2

Source: http://www.trekla.net/signup/index_htm_files/Trek%20LA%20Emergency%20Medical%20Form.pdf

Microsoft word - geneesmiddelen en rijvaardigheid 2009.doc

Rijgevaarlijke geneesmiddelen Inleiding Het Centraal Bureau Rijvaardigheidsbewijzen (CBR) is een Zelfstandig Bestuursorgaan (ZBO) dat door de overheid is aangewezen om bepaalde wettelijke taken uit te voeren. Het CBR is zelf geen overheid, maar een stichting die zijn eigen inkomsten genereert uit door de Minister van Verkeer en Waterstaat goedgekeurde tarieven. Het CBR is vooral beken

Microsoft word - eaa newsletter march 2009.doc

Monthly Meetings held on the first Thursday of each month at 7:00 PM - Barstow Airport (3BS) Volume XV Issue 3 Officers Class II Directors ___________________________________________________________________________________________________________ SPECIAL EVENTS – 2009 CALENDAR OF EVENTS – 2009 Robert Shafer featured Speaker at Chapter Meeting March 5, 2009 Ditching,

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