LAOO Medical Authorization Form

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Please complete the following information:

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In case of accident or illness, I give my authorization to the chaperones of Lake Highland Preparatory School to contract for medical treatment of the below named student. I also give my permission for the participant listed below to take any over-the–counter medications as needed with the exception of _________________________ (if any) while attending the program. The permission is valid for the period of time between June 2, 2020 through June 8, 2020.

Please enter any over-the-counter medicine your child CANNOT take (if any) below.

If your child requires over the counter medications, we are able to dispense medications in relation to those privileges provided on PowerSchool.

I understand and agree with the stated policy regarding over-the-counter medications.

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If your child will be bringing prescription medications, please list them on the form below. Students will dispense their own medications unless you deem it to be handled by an adult/platoon leader. If your child has a prescription that needs to be refrigerated, we are able to provide this.

Students who may be injured during the time at Leadership Academy at Outdoor Odyssey will be evaluated and treated on-site. If the student is able to continue in the training, they will be treated and return to their platoon. If the student is going to be removed from activity, parents will be contacted at this time and further treatment and/or evaluations will be discussed. In case of emergency, we will transport to the nearest hospital.

I understand and agree with the stated policy relating to injuries at Leadership Academy.

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In the case that your child has a tick, it will be removed on the premises for the safety of the child. If your child has any adverse reactions or needs continued care, a parent/guardian will be notified at that time.

I understand and agree with the stated policy relating to tick removal.

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Signature *

Please type parent/guardian full legal name below.

Confirmation *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Required

Today's Date *

YYYY

Participant First Name *

Please enter your child's first name.

Participant Last Name *

Please enter your child's last name.

Gender *

Please enter your child's last gender.

Female

Male

Date of birth *

Please enter your child's date of birth.

YYYY

Year of last tetanus shot *

Please enter the year of your child's last tetanus shot.

Describe any medical condition (if any) that a physician would need to know about prior to emergency treatment:

Is your child currently under a physician’s care for any condition (physical, mental, or emotional)?

If yes, please list below

What medication (if any) is your child taking?

List any medication in your child's possession that he/she may self-administer (i.e. over the counter drugs).

List any allergies your student has to food, medication, animals, insects, etc.

List any dietary restrictions.

EMERGENCY PHONE NUMBERS

Family Doctor's Name *

Family Doctor's Phone Number *

Parent's Home Phone Number *

Parent's Cell Phone Number *

Alternate Contact Person Name *

Alternate Contact Person Phone Number *

Name of Health Insurance Company *

Health Insurance Policy Number *

Health Insurance Company Phone Number *

Send me a copy of my responses.

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