LEIGH PERFORMING ARTS MEDICAL INFORMATION / PARENT CONSENT
**ALL INFORMATION GIVEN WILL REMAIN CONFIDENTIALLY ON FILE UNTIL DESTROYED AT THE END OF THE SCHOOL YEAR**
STUDENT’S DOB: ________/________/________ CITY & STATE OF BIRTH: _________________________________
STUDENT’S ADDRESS: __________________________________ CITY & STATE: ______________________________
HOME PHONE: __________________________________ CELL NUMBER: __________________________________
FATHER’S NAME: __________________________________ MOTHER’S NAME:______________________________
FATHER’S WORK:__________________________________ MOTHER’S WORK: _____________________________
WORK PHONE: ____________________________________ WORK PHONE:_________________________________
ALT. PHONE: ______________________________________ ALT. PHONE: __________________________________
EMERGENCY CONTACT INFORMATION (REQUIRED):
NAME & RELATIONSHIP: __________________________________________ PHONE: _______________________
FAMILY DOCTOR NAME: __________________________________________ PHONE: _______________________
SPECIAL MEDICAL NEEDS, HEALTH PROBLEMS, PHYSICAL RESTRICTIONS (IF NONE, WRITE NONE):
ALLERGIES TO FOOD, MEDICINE, INSECT STINGS, ETC (IF NONE, WRITE NONE):
CURRENT MEDICATION BEING TAKEN * (IF NONE, WRITE NONE):
*Students taking medications on a regular basis are required to turn in these medications to he held in a secure place on
any extended trip. A complete list of the student’s medications and when they are to be taken must be included.
Medications must be in the original prescription container. Students wil be able to take their medications as needed. If your
child uses an inhaler, please have them carry it at al times.
I am aware of my child’s participation in the 2012-2013 LHS MARCHING BAND AND COLOR GUARD with LEIGH HIGH SCHOOL PERFORMING ARTS. I am aware that taking part in this activity carries the risk of injury to my child, particularly due to travel, practice and performance. The directors, instructors, sponsors, and parents/chaperones have my permission, in an emergency situation when I cannot be contacted, to seek medical assistance at a medical clinic or hospital emergency room at my expense. I certify that I have adequate insurance coverage as stated below and I accept ful responsibility for any medical expenses arising due to the injury or il ness of my child while participating as a member of the organization.
PARENT/GUARDIAN SIGNATURE: ____________________________________ DATE: _________________
PRINTED NAME OF POLICY HOLDER: ________________________________________________________
INSURANCE COMPANY: _________________________________________________________________
POLICY NUMBER: __________________________ GROUP NUMBER: ____________________
**WE MUST HAVE A COPY OF YOUR INSURANCE CARD TO KEEP ON FILE WITH THIS FORM** AUTHORIZATION TO TREAT A MINOR
I (we), the undersigned parent/guardian of ____________________________________________________ , a minor, do hereby authorize and consent to any medical treatment rendered under the general or special supervision of any member of the medical profession and emergency room staff. I give my permission to directors, instructors, sponsors, and /or chaperones to administer over the counter drugs and first aid for emergency use only. I have indicated below what medications can be given to my child. Those administering the treatment wil fol ow the directions on the medication unless otherwise noted in the child’s medical form.
Please initial next to what your child can be given in an emergency. (Emergencies wil be determined by the director/instructor/sponsor/chaperone.) Medications listed could be a variation of the specific brand name or a generic brand.
________ Tylenol ________ Advil _________ Imodium ________ Benadryl ______Tums ________ Dramamine
________ Pepto-Bismol ________ Cough Drops _________Aspirin _______ Sudafed _______ Aleve
List any restrictions:____________________________________________________________________________
PARENT SIGNATURE: _________________________________________________ DATE: ___________
coMponEnts of tEchnoloGIcal KnowlEdGE: IndIcators of proGrEssIon lEvEl sEvEn Teachers should establish if students have developed robust level six understandings and are ready to begin working towards level seven achievement objectives for technological knowledge and plan learning experiences to progress these as guided by the level seven Indicators below. technologica
MeRA Test Microbiological test with spores of Geobacillus stearothermophilus for the detection of antibiotic and sulphamide residues in meat DESCRIPTION Antimicrobial substances are given to cattle for therapeutic treatment of infections and so they can be present in meat as residual drugs. The presence of residual antimicrobial drugs in meat is a potential hazard for the consumers si