Disney Band Trip 2017 Medical Forms Medicine Procedures Student Pledge The following 4 pages contain Student Medical Forms, which need to be filled out and returned by Friday, January 13, 2017. Please try to complete these and return them on time. We will need these medical reference forms should the need arise to help your child while on the trip. Once again please try to return them on time as someone will have to go thru them and sort them and get them into a binder so they can be accessed quickly if necessary. Medicine Procedures First of all, students can come to any chaperone if they don t feel well or need any kind of assistance. We also have two Chaperones designated as Medical Chaperones. These two Medical Chaperones will have all the Student Medical Forms and track any interventions. What we would like to establish is a procedure for routine medicines that students need to take at a scheduled time while on the Disney trip. Here is the plan for these type of student needs: LEVEL 1 STUDENT MEDICINE NEEDS We would expect to have just a few of these students. These students would need direct assistance with taking their medicines. They would also need frequent monitoring. LEVEL 2 STUDENT MEDICINE NEEDS - Most of the students who will be taking routine medicines we would expect to be in this category. These students would keep their medicines with them personally. They would be reminded by their room chaperone at the start of each day to be sure to have their meds with them and know their scheduled time. They would be responsible to take their medications on schedule or call their chaperone if they need assistance. They would be checked at the end of each day to make sure they indeed did take their medicine on time and if there were any problems with that. Both Level 1 and Level 2 students could additionally be accountable to their parents via text messaging at scheduled medicine time. We would like that. For all Students, each park has a medical station near the park entrance. They can go there anytime they need assistance. If a student enters the Disney Park Medical Station, and identifies themselves as being a Bullock Creek Band member, the Supervising Chaperones will get a phone call. We can then meet the students there and assist. The students can also call any of the chaperones if they need assistance and we can get to them ASAP and help them get to the medical station. The students will be given business cards with every chaperone s cell phone number for this purpose. When filling out the Medical Forms that follow, please indicate if your child would be a Level 1, Level 2, or Not Applicable. We will then be able to forge a list of particular students whom we need to monitor for medical observations and assistance.
{ Page Left Blank }
Medical Information Emergency Permission to Treat Midland Bullock Creek High School Band Form Effective Dates: January, 2017 June, 30 2017 Please Check Student Information Last Name First Name Birth Date Street Address City Zip Code LEVEL 1 LEVEL 2 NOT APPLICABLE Student Cell Phone Parent/Guardian Information Mother (Guardian) Phone (Primary) Phone (Secondary) Father (Guardian) Name Phone (Primary) Phone (Secondary) Mother (Guardian) Email Address Father (Guardian) Email Address Emergency Contact Information Emergency Contact Name (Primary) Phone (Primary) Phone (Secondary) Emergency Contact Name (Secondary) Phone (Primary) Phone (Secondary) Insurance Information Medical Insurance Company Insurance/Employee ID Number Group Number (if Applicable) Name of Family Medical Practitioner City Phone ( 1 of 4 )
Medical History Medical Pg. 2 Date of Last Tetanus Shot given. If left blank, in the event of an emergency, a tetanus shot WILL be Does the student wear (please check all that apply): Glasses Contact Lenses Braces/Retainer Splints/Joint Braces or Supports Does the student have, or ever had, any of the following (check all that apply): Asthma Diabetes Dizziness/Fainting Eating Disorder Epilepsy/Seizure Disorder Frequent Upset Stomach or Digestive Issues Heart Trouble Low/High Blood Pressure Low Blood Sugar (Hypoglycemia) Motion Sickness Muscle, Joint or Back Problems Physical Handicap Sinus Problems Food Restrictions Other Please explain any of the above: Please list and explain any surgeries or major illness the student has had in the last year: Please explain any physical and/or psychological ailments, illnesses, weaknesses, limitations, handicaps, or conditions listed or not listed above which might hinder any activity students might perform during the course of the effective dates of this form. Please list any prescription medications that the student will be taking while on this trip: ( 2 of 4 )
Medical Pg. 3 Does the student require any of the following prescription medications (check all that apply): Inhaler Please list type and explain: EpiPen Please list type and explain: Other Please list type and explain: Please list any allergies the student may have to the following: Medications : Foods : Latex : Sunscreen : Pollen, Insect Bites, Other : ( 3 of 4 )
Medical Pg. 4 Parent/Guardian Permission and Pledge Parent/Guardian & Student Permission, Liability and Pledge Signature Form I give permission, as parent/guardian for my student s participation. I further entrust my student s care and supervision to the Band Director, and Chaperones. Furthermore, I understand chaperones and adult supervisors can only help maintain my student s safety and well being to the degree that he/she follows all behavior guidelines and health guidelines and that it is his/her responsibility to adhere to all of these Band guidelines. Even with all precautions and guidelines being followed, there are circumstances referred to as acts of God which can occur. By signing this form, I agree that my student(s) may participate in the Bullock Creek Band related activities held during the course of the school year, and to release, waive, discharge, and covenant not to sue, and agree to hold Bullock Creek Band and/or Bullock Creek School District and/or Traverse City Christian School, their trustees, officers, servants, agents, volunteers and employees from and against any and all liabilities, demands, claims, or injuries, including death, that I may sustain during or in conjunction with the activities. I agree to stop and seek assistance if I do not believe I can safely continue, and to refrain from any and all actions that would pose a hazard to myself or others. Parent/Guardian Signature Date Student Pledge I agree to uphold the following: Respect others and their property help to maintain a clean environment in all areas. Follow all cell phone requirements outlined in this handbook. Refrain from the use of alcoholic beverages, controlled substances (drugs) and tobacco per School Code. Show consideration and respect for others, particularly in being sensitive in manner of speech and dress (modesty), and by maintaining an appropriate standard of personal hygiene, and acting as mature young adults. Refrain from going into designated area for the opposite gender. Refrain from public (AND non-public) displays of affection. Couples must refrain during Band activities. Resolve any conflicts in an appropriate manner. Respect the Band, tour company, hotel, Disney and facilities by putting garbage in cans provided, keeping all areas clean and safe, and not leaving personal items lying around. Think before doing anything questionable. Ask an adult if unsure. Furthermore, I understand chaperones and adult supervisors can only help maintain my safety and well being to the degree that I follow all behavior guidelines and health guidelines and that it is my responsibility to adhere to all of these Band guidelines. Even with all precautions and guidelines being followed, there are circumstances referred to as acts of God which can occur. By signing this form, I agree to follow all guidelines and that I may participate in the Bullock Creek Band related activities held during the course of the school year, and to release, waive, discharge, and covenant not to sue, and agree to hold Bullock Creek Band and/or Bullock Creek School District and their trustees, officers, servants, agents, volunteers and employees from and against any and all liabilities, demands, claims, or injuries, including death, that I may sustain during or in conjunction with the activities. I agree to stop and seek assistance if I do not believe I can safely continue, and to refrain from any and all actions that would pose a hazard to myself or others. I have read the information regarding this band trip in this handbook in it s entirely with my parent/guardian. I pledge, in good faith, to follow all rules of good conduct, behavior, policy, and scheduling. I further will respect all property and be considerate of all other persons. I will be a responsible young adult and will represent myself, Bullock Creek High School, and especially the Bullock Creek Band as an exemplary young adult Creek Classy! Student Signature Date ( 4 of 4 )