**DO NOT UNSTAPLE THIS PACKET**

Transcription

1 Bryant Elementary October 22-26, 2018 Please complete this packet and return to Mr. Wood no later than September 14, 2018 STUDENT ENROLLEMENT FORMS **DO NOT UNSTAPLE THIS PACKET**

2 Bryant Elementary Outdoor School Program Emergency/Health/Medications Information (Parents: Complete ALL forms and return to outdoor school director) Student s Full Name Birth date / / Age Sex (circle one): Male or Female Home Address City Zip Home Phone Cell Phone Work phone (dad) Work phone (mom) Family doctor Phone If unable to reach parent in an emergency, please contact Phone Relationship Date of last tetanus shot (REQUIRED) Has your child required hospital treatment in the last year? yes no How many times? Does child have any history of: Diabetes Hives Stomach problems Bed wetting Date of last occurrence Seizures Frequent headaches Migraines Asthma Other health problems not listed above State treatment given for any items checked above

3 Please list allergies and type of reaction: Allergic to: Type of reaction: Is child sensitive to: Poison Ivy Sunburn Insect bite (mosquito, chiggers) Insect sting (bee, wasp, hornet requiring Epipen) Does your child have any physical limitations that we need to be aware of: Has your child been away from home before for several days? Is it likely your child will become homesick? If so, do you want to be called at any hour? Please list any other information that you feel we need to know about your child:

4 Parent Agreement My child has permission to attend outdoor school October 22-26, 2018 with Bryant Elementary. I understand that students will be in the woods and other rugged terrain for nature and environmental study part of each day. An adult will supervise all students. Information about my child s medical condition and/or medications may be shared with the adults on an as-needed basis (Bryant employees and cabin parents) who will be caring for him/her. In case of medical emergency, I understand I will be contacted as soon as possible. I give permission for Moore Public Schools/Bryant Elementary Staff to transport my child to a hospital or medical office if necessary to secure emergency medical care. I also understand that Bryant Elementary and Moore Public Schools will not be held liable for accidents and injuries obtained at Camp Classen. Signature of Parent/Guardian: Date: Student Agreement I understand that my participation in the Outdoor School Environmental Program depends upon: 1. My active participation in all activities 2. My responsibility for all duties assigned me 3. My following all Outdoor School rules for safety and group living. I understand that failure to assume these responsibilities may result in loss of privileges or in being sent home. Signature of Parent/Guardian: Date: Photo Release Waiver Photo Release: I hereby give representatives of Bryant Elementary and Moore Public Schools the unqualified right to take pictures of my child while he/she is attending the Bryant Elementary Outdoor Education Program at Camp Classen and to place the finished pictures on the Bryant Elementary/Moore Schools web site and/or the Bryant Elementary Facebook Page. I understand that these pictures will be accessible to anyone with Internet access and may be used in instructional settings. NO children s names will be published. Signature of Parent/Guardian: Date:

5 INSURANCE Insured Subscriber s name: Subscriber s DOB: Medical Insurance Carrier: Ins. Carrier Phone: Medical Insurance Billing Address Subscriber s Policy # ID # I am attaching a copy of BOTH sides of my insurance card. I will assume responsibility for any medical charges not covered by the insurance company. I will snap a picture of BOTH sides of my insurance card with my phone and it blakewood@mooreschools.com from the following My child has no insurance coverage, but I will assume responsibility for medical charges incurred by my child. Parent Signature: Date: BOATING PARENTAL PERMISSION *Life jackets will be required and provided by the camp grounds. My child MAY CANOE/ KAYAK MAY NOT CANOE/KAYAK HORSEBACK RIDING PARENTAL PERMISSION *Riding helmets will be required and provided by the camp grounds. My Child MAY HORSEBACK MAY NOT HORSEBACK Parent Signature: Date: Student T-shirt Size Please circle one Youth-M Youth-L Adult-S Adult-M Adult-L Adult-XL Adult-XXL Adult- XXXL

6 Student Name: Please list all types of medications your child will be taking (including over the counter) *** Please note: Moore Public School medication consent form will be REQUIRED for each medication listed below. This must be signed by the parent & doctor!!! *** If we do not have a medication consent form we cannot give your child medication. Name of Medication Dosage Amount Circle Time(s) of Day Given Day(s) Given Monday Tuesday Monday Tuesday Monday Tuesday Monday Tuesday Monday Tuesday Monday Tuesday

7 Moore Public Schools Parent Medication Consent Form (It is recommended to give medications at home if possible.) Student: School: Teacher: Gr: If it is necessary, that a medication be given during school hours the following regulations must be met: *Medication must be ordered/advised by a physician/dentist and permission granted for the school staff to contact the prescribing physician/dentist if necessary regarding this medication. *Prescription medication must be brought to school in the ORIGINAL container with appropriate label intact. The label must have the student s name, name of medication, dosage, and time to be given. IF MEDICATION IS NOT PROPERLY LABELED, IT WILL NOT BE GIVEN. *Non-prescription medication must be in the ORIGINAL, UNOPENED container and accompanied by a physician request and instructions for administration at school. The physician request must include student s name, name of medication, dosage, and time to be given. *Medication cannot and will not be accepted in baggies or envelopes. *Parent/guardian MUST sign this form, granting designated school employee permission to give the medication during school or during school-sponsored activities, according to school policy. *For your child s safety, the parent/guardian must bring prescription/non-prescription medication to the school, rather than sending it with the student. At the end of the school year, any remaining medication must be picked up by the parent/guardian or it will be discarded by the school. The school cannot send medications home with students. Students CANNOT carry medications on their person. The only exceptions are emergency medications such as rescue inhalers, epi-pens and insulin. These medications must have a medication consent form on file, signed by a parent/ guardian and a physician, stating the student can carry the medications. It is highly suggested that you provide a back-up medication to the office. *By signing this form, the parent with legal custody or guardianship understands that under state law the Board of Education, the Moore School District, or employees of the District shall not be liable to the student or the student s parents or guardian for civil damages for any personal injuries to the student which result from acts or omissions of school employees in administering the medication. *The parent/guardian agrees to provide medication and any particulars connected with administering medication at their own expense. *The parent/guardian will promptly notify the school of any change in the administration of this medication and will provide the school with new prescription bottle and physician order. Written or verbal changes from parent/guardian CANNOT be accepted. *The parent/guardian will notify the school of any physician change and obtain a new written prescription. PLEASE FILL OUT THE FOLLOWING. ALL MEDICATIONS MUST HAVE THE FOLLOWING FILLED OUT BY A PHYSICIAN/NURSE PRACTITIONER/ PHYSICIAN S ASSISTANT. This form will only be valid for the current school year. A new form is required yearly. PLEASE USE A SEPARATE FORM FOR EACH MEDICATION Medication: Diagnosis: Trade name or generic Dosage: Time(s) to be given at school: Method of administration: ORAL Liquid Tablet Inhaler Drops: Eye R L Ear R L Topical: apply where Other: Effective Dates: From / / to / / Possible side effects: If medication is PRN (as needed), please specify: Signs and symptoms Can medication be repeated? Yes No How many times? Frequency of Administration Physician s Name (Please print) Physician signature Physician s phone Date TO BE COMPLETED BY THE PARENT/GUARDIAN: I have read the procedure for medication administration and I hereby request and authorize Moore Public Schools personnel to administer this medication as directed. I agree to release, indemnify, and hold harmless Moore Public Schools and any of their officers, staff members, or agents from lawsuit, claim, demand, or action against them for administering medication to this student. I understand that permission is granted for exchange of verbal and/or written communication between the school staff and the prescribing physician/dentist regarding this medication. Signature of Legal Parent/Guardian Date Nursing 3/11

8 CONTRACT FOR EXCEPTION: TO SELF-ADMINISTER AND RETAIN MEDICATION ON PERSON *Provisions under 70 O.S. 1984, Section and the Moore Public Schools Policy #7150 allow a student to self-administer a prescribed asthma, anaphylactic medication or diabetic medication. Approval to self-administer medications must be authorized by the prescribing physician. The parent/ guardian of the student is to provide the school an emergency supply of the student s medication. I have instructed in the proper use of his/her medication and it is my professional opinion that this student is capable of self-administration of the medication and should be allowed to carry and use that medication by himself/herself. / / Physician signature Date I understand this request is governed by Moore Public Schools regulations on self-administration of medication and there are conditions and exceptions to self-administration. I have instructed my child to inform school personnel if symptoms persist so additional emergency care can be obtained, if needed. I also understand that this permission may be revoked if my child misuses the medication. I understand that Moore Public Schools, its agents and employees shall incur no liability for any adverse reaction or injury suffered by this student as a result of self-administration. We, the undersigned, absolve the school of any responsibility in safeguarding our child s medication. Signature of Legal Parent/Guardian / / Date ** This form must be signed by both the child s parent & the child s doctor in order for any medication to be given to the child while at Camp Classen October 22-26, This includes all prescription medications and over the counter medications. ** MEDICATION CANNOT BE GIVEN TO YOUR CHILD WITHOUT THIS FORM COMPLETED BY BOTH THE PARENT AND THE DOCTOR. WE CANNOT ACCEPT VERBAL CONSENT.

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