2021-22 Emergency Medical Form

2021 HGFA EMERGENCY MEDICAL FORM

PLEASE FILL OUT ONE FORM PER HORIZONS STUDENT.
STUDENT INFORMATION
Student Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Gender
Student Birth Date
MM slash DD slash YYYY
PARENT/GUARDIAN INFORMATION
Parent/Guardian 1 Name
First Last
Parent/Guardian 1 Relationship to Student
Guardian 1 Phone
Guardian 1 Alternate Phone
Parent/Guardian 2 Name
First Last
Parent/Guardian 2 Relationship to Student
Guardian 2 Phone
Guardian 2 Alternate Phone
EMERGENCY CONTACT INFORMATION
Please provide the name and phone numbers of two relatives, friends, or neighbors who we can contact in the event we cannot reach you if necessary. DO NOT list parent or guardian as an emergency contact if already listed on this form above. An emergency contact must be willing to pick up your sick child at GFA if needed.
Emergency Contact 1 Name
First Last
Emergency Contact 1 Relationship to Student
Emergency Contact 1 Phone
Emergency Contact 1 Alternate Phone
Emergency Contact 2 Name
First Last
Emergency Contact 2 Relationship to Student
Emergency Contact 2 Phone
Emergency Contact 2 Alternate Phone
STUDENT'S MEDICAL PROVIDERS
Student's Doctor
First Last
Doctor's Phone
Dentist Name
First Last
Dentist Phone
STUDENT MEDICAL INFORMATION
Please answer the questions below to provide current health and medication information to staff. In the unlikely event of an emergency, this information may be shared with Emergency Medical Services personnel. Please notify the Horizons nurse immediately regarding any change in your child’s medical information.
1. Does your child have any medical conditions?
If yes, please list medical conditions below.
2. Does your child have any allergies?
If yes, please list all allergies below.
3. Does your child take any medications, either prescription or over-the-counter, on a daily or regular basis?
If yes, please list medications below.
4. Will your child require the administration of any medication, either self-administered or by the staff, while attending Horizons?
If you answered yes, please list all medications below that will be taken while on the GFA campus.
If you answered yes to this question, please print out and complete the Authorization for the Administration of Medication Form (http://www2.tmsc.org/CTMedAuthForm.pdf) or contact our office for one to be mailed to you. This form must be completed by the child’s authorized prescriber and signed by the child’s parent or guardian. Please submit the completed form to Horizons by June 10th. Medications must be delivered to the nurse by a responsible adult on the first day of the program.
PERMISSION TO ADMINISTER PAIN RELIEVER
ACETAMINOPHEN (TYLENOL): The Horizons nurse may administer Acetaminophen to a child for headache, menstrual cramps, orthodontic pain, or other pain according to the Standing Orders of the summer programs’ medical advisor, and the professional judgment of the nurse. The Standing Orders allow up to two (2) doses per month for students through 8th grade.
Please indicate your permission for the Horizons GFA Nurse to administer Acetaminophen (Tylenol) to your child as needed by placing your initials here. (If you do not initial, the nurse will NOT administer Acetominophen to your child in the event of issues listed above.)
IBUPROFEN (MOTRIN/ADVIL): The Horizons nurse may administer Ibuprofen to female students with menstrual cramps. If a student requires Ibuprofen more than four times in any given month, an order from the student's authorized prescriber is required.
Please indicate your permission for the Horizons GFA Nurse to administer Ibuprofen (Motrin or Advil) to your child as needed by placing your initials here. (If you do not initial, the nurse will NOT administer Ibuprofen to your child in the event of issues listed above.)
MEDICAL EMERGENCIES POLICY
In the event of a medical emergency, serious accident, injury, or illness, as determined by the GFA/Horizons nurse or another responsible staff member, it is the policy of Greens Farms Academy to call 9-1-1 immediately for EMS assistance and transport to the nearest approved medical facility. Emergency interventions, as ordered by the child’s physician or summer program medical advisor will be implemented in the interim, as appropriate. Best efforts, reasonable under the circumstances, will be made to contact you and/or your child’s doctor at the numbers you have provided on this form. Your child will receive medical care and treatment necessary to sustain life and/or stabilize his/her condition, as determined by the medical facility. Any further treatment must be authorized specifically by you, or the person(s) designated by you.
Parent/Guardian Name
First Last
By initialing below, I attest that I have read and understand the HGFA Medical Emergencies Policy.
Date Signed
MM slash DD slash YYYY