Medical Form – Private And Confidential

Student Information

MM slash DD slash YYYY

Travel/Health Insurance: (if applicable to trip)

Allergies

Are any allergies Anaphylactic:
Do you carry an epi pen:

Medical History

Please list any prescribed medications you are currently taking or have recently taken within the last 3 years: (if none, please indicate so)
Currently Taking:
Currently Taking Dosage:
Recently Taken:
Recently Taken Dosage:
 
Are you Vegetarian
Are you Vegan
Are you Gluten-free
Are you Lactose-Intolerant
Physical Condition : Eyesight
Physical Condition : Swimming Level

Please check Yes or No if you give permission for a supervisor/teacher to administer the following over the counter medications during the course of the trip.

Acetaminophen (Anacin, Tylenol), Naproxen (Aleve), Reactin (Cetirizine) - Analgesic for mild to moderate pain
Ibuprofen (Advil, Motrin) - Analgesic for mild to moderate pain
Dimenhydrinate (Gravol) - Antiemetic drug for motion sickness, nausea and vomiting
Glucose tablets - Anti Hypoglycaemic use when blood sugar use is reduced and unable to consume normal solids
Electrolyte solutions - Oral rehydration salts, replaced depleted salts due to excessive sweating or diarrhea
Diphenhydramine (Benadryl) - Antihistamine for runny nose, itchy/watery eyes, reaction to insect bites
Loperamide Hydrochloride (Imodium) - Antidiarrhoeal for the relief of acute diarrhea
Homeopathic Remedies: Rescue Remedy - Trauma
Homeopathic Remedies: Arnica/Traumeel/Calendula Cream - Preparation used to relieve muscle pain and inflammation due to injuries (sprains, bruises, etc.)

Family Doctor:

Please provide contact information in case of emergency

Emergency Contacts:

In signing this Medical Form that consists of two pages, I am indicating that I know of no reason why my child should not participate in the excursion. In addition, in the event of an emergency I hereby authorize any member staff accompanying the trip to consent to such medical treatment, including inoculations, surgery, medicine, or blood transfusion, as may be necessary for my child in the event of accident, injury and/or illness in the opinion of a qualified medical practitioner.