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Emergency Medical Release Form 2005-2006
Please complete each section thoroughly, sign and date.
The Awty International School
A new form must be completed each school year and is required for enrollment.
Student’s Name: ___________________________________________________________________________ Sex: F □ M □
Last First
irthdate _______________ Age: _______ 2005-2006 Grade Level: _________________ Section: French International
Mother’s Name: ____________________________________________Home phone number: (______)______________________________

Work number: _(______)_________________________ Cellular number: _(______)_____________________________

Father’s Name
: ________________________________________Home phone number: _(______)__________________________
Work number: _(______)_____________________________ Cellular number: _(______)_________________________________


ALLERGIES:
Does your child have any allergies to food, medications, insects, etc.? □ Yes □ No
If Yes, please list: ____________________________________________________________________________________________________ your child require an Epinephrine Pen for this allergy? □ Yes □ No
HEALTH CONDITIONS:
Has your child, currently or in the past, been diagnosed with any of the following health conditions (check all that apply) :
Asthma
□ Yes □ No Epilepsy/Seizure Disorder □ Yes □ No
Vision/Hearing Problems □ Yes □ No
□ Yes □ No
Frequent/Migraine Headaches □ Yes □ No
Chronic Ear Infections □ Yes □ No
□ Yes □ No Attention
Deficit-Hyperactivity □ Yes □ No

If Yes, please explain: _____________________________________________________________________________________________________

List any other health condition(s) not listed above
:_______________________________________________________________________________

List any medication(s) currently taken by your child. _________________________________________________________________________________________________


Name of Child’s Physician in USA: ____________________________________________________________________________

Physician’s phone number: (________)___________________________________


Name of Insurance Company
: ____________________________________________________________ Policy #:

In case of emergency, take my child to the following hospital (please complete one
):
Additional person authorized to pick up my child and/or to contact in case of an illness or an emergency:
Name: ______________________________________________ Relationship ___________________ Phone number: _(_____)_______________

M E D I C A T I O N A D M I N I S T R A T I O N
Non-prescription Medication listed below is available in the Clinic for parents to request for their child. This medication is given after initial evaluation of your child’s symptoms. All medications are given in accordance with the packaging label on the product, by age and weight-appropriate strengths. I hereby authorize The Awty International School clinical staff to administer medication checked below to my child while on campus and/or during school-sponsored activities off-campus. [ ] No medications
[ ] Acetaminophen (e.g. Tylenol -Children’s, Jr. & Adult strengths)
[ ] Antibiotic ointment (e.g. Neosporin) for cuts and scrapes
[ ] Itch stopping cream (e.g. Calamine Lotion) for mosquito/ant bites
[ ] Throat Lozenges (e.g. Halls cough drops)
[ ] Sterile eye wash (e.g. Bausch & Lomb) for dirt/foreign matter in eyes
[ ] Benadryl Liquid (for severe allergic reactions) [ ] Ibuprofen (e.g. Advil, Motrin)
[ ] Tums for upset stomach (students 12 years or older)
E M E R G E N C Y R E L E A S E
If, in the judgment of any responsible person employed by The Awty International School, the student named above needs immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize and consent to such care and treatment as may be given to said student by any medical personnel or school representative. I do hereby agree to indemnify and hold harmless The Awty International School and any school representative from any claim by any person whomsoever on account of such care and treatment of said student.
Signature of Parent/Guardian

Source: http://www.t2d.net/awty/pdf/blueFrm.pdf

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