Guideddiscoveries.org

CIMI Tall Ship Expeditions Aboard SSV TOLE MOUR
STUDENT APPLICATION –MEDICAL FORM SCHOOL: _______________________________________
STUDENT INFORMATION (COMPLETE IN FULL)
Do not staple or copy on colored paper dent and explain below.
q Asthmaq Backaches or weak backq Bowel or bladder problems q Car/Sea sicknessq Epilepsy or convulsive disorder q Hay feverq Headacheq Heart trouble or murmur Is student capable of participating in snorkeling and hiking? q Yes q No Is the student required to take regular medication? Yes___ No___ (all medications are administered by the chaperones from the student’s own school)Please provide instructions (dose) for administration of medication:Is the student taking medication for ADHD or ADD? Yes___ No___Does the student have an inhaler? Yes___ No___ When should it be taken, and are there any warnings?Check those nonprescription medications we may have permission to give your child under the supervision of your child’s classroom teacher.
___ ___ Milk of Magnesia (for constipation) ___ ___ Chloraseptic Spray (for sore throat) ___ ___ Acetaminophen (Tylenol generic for headaches or elevated temperatures) ___ ___ Bonine, Meclazine or Dramamine (seasickness) Medical Consent
The student’s medical conditions stated on this application are complete and correct. I hereby give permission to the Catalina Island Marine Institute (CIMI) camp personnel to administer First Aid and to arrange for medical care and treatment in case of a medical emergency. I also give permission to the physician selected by CIMI camp personnel to examine, diagnose and treat or secure proper treatment for the student as the physician shall determine is proper and necessary under the circumstances. A photocopy of this authorization shall be as valid and may be accepted as the original.
Parental Authorization
I have been informed of the nature of the CIMI program in which the student is enrolled. I understand there are risks associated with the student’s participation in the program activities generally described in this pamphlet and transportation to and from the camp, which pose a threat of injury, illness or death. The undersigned is familiar with outdoor sports and activities and the student’s abilities, and I am not aware of any physical, emotional or mental problem or limitation that would prevent, impair or increase the risks involved in the student’s participation in CIMI activities.
With this knowledge, I grant permission for the student to participate in all camp activities and on behalf of the undersigned and the student I accept and assume the risk and full responsibility for injury, illness, death or loss of personal property or other damage, and medical or other expense resulting from the student’s presence at CIMI.
I hereby release and discharge Guided Discoveries, Inc., CIMI and their agents and employees from liability to us and to the student for any and all losses, damages, and expenses and any injury to person or property, including death, resulting from the student’s travel to or from CIMI and participation in the program.
I agree to direct the student to comply with all CIMI rules and policies and to cooperate with CIMI personnel. I understand and agree that if the student fails to comply with the rules and policies, he or she may be expelled from CIMI and sent home at my, parent or legal guardian’s expense. Also, I give permission to CIMI to use photographs or video taken of my child in their promotional literature and other printed materials.
Date________________________________________________Signature_______________________________________________________ Rules for acceptance and participation in Guided Discoveries programs are the same for everyone without regard to race, color, national origin, sex or handicap.

Source: http://guideddiscoveries.org/documents/tallshipmedform2013.pdf