_______________________________________________________________________________ ‘Semana Santa’ Departure-Guatemala 2006 Departs April 7th 10 day trip: returns April 16th (Antigua and Lake Atitlan) 12 day trip: returns April 18th (includes exploration of Yaxhá & Tikal ruins) Signature Experiences • Positive Impact Visit in Santa Cruz del Quiche with families benefiting fr
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Emergency contact informationTabb Tiger Band 2012-2013
Consolidated Medical Form
Student Name _______________________________________________ Home Address ______________________________________________________________________________________ Home Phone # ______________________ Primary Doctor with Phone #: ______________________________________ d/Drug Allergies: NONE KNOWN OR YES, as noted here ________________________________________ NONE KNOWN OR YES, as noted here ________________________________________ Current Medications: _________________________________________________________________________________ __________________________________________________________________________________________________ Every effort will be made to contact the parents in the event of any serious injury or illness to their child. Please print clearly! Parent/Guardian and Emergency Contact Information
Tabb Tiger Band 2011-2-11
Father’s Name (or Guardian) ______________________________________________ Home Phone # _______________ Work Phone # _______________ Cell Phone # _______________ Mother’s Name (or Guardian) _____________________________________________ Home Phone # _______________ Work Phone # _______________ Cell Phone # _______________ Additional Emergency Contact Name _______________________________________ Phone # ______________ Additional Emergency Contact Name _______________________________________ Phone # ______________ Student Medications
NO STUDENT MAY CARRY HIS or HER OWN MEDICATION. This applies to both prescription AND over-the-counter
medications. If your child needs to bring medication on a trip, it must be given to the designated chaperone for safekeeping. Please provide only the amount needed for that specific trip in a PHARMACY-LABELED CONTAINER.
The following over-the-counter medications are carried by a designated parent chaperone to dispense to Band members on
an emergency basis—according to the dosages stated below—whenever the Band travels to football games, competitions,
and on any other scheduled Band trips. It is very important that you review the list of medications below, and cross out
any medications that your child is not authorized to receive. No other medications are carried in the Band’s first aid kit.
Imodium AD (Loperarnide HCL) anti-diarrhea Excedrin Migraine (250mg acetaminophen + 2 geltabs with water, only once in 24 hrs Bismuth subsalicylate (generic Pepto Bismol) Sudafed PE (phenylephrine HCI) decongestant Diphenhydramine HCI (Benadryl) antihistamine Zinc Oxide Cream, Lanacane and Solarcaine sprays Acetaminophen (Tylenol and generic Tylenol) Expiration dates on all over-the-counter medications carried in the band’s first-aid kit 50mg/1-2 tablets every 4-6 hours, up to 8 in 24hrs are checked regularly and replaced before the Medical Release Authorization
Insurance Carrier _______________________________Policy ID # or Sponsor Name__________________________ I hereby authorize emergency medical treatment to be administered to the above-named student while traveling or performing with the Tabb HS Band. The student is covered by the identified company and policy, and I agree to pay any additional medical or transportation expenses that arise from any emergency, whether medical or behavioral. I give my permission to the designated Band chaperone to dispense medications in accordance with policy stated above.
Guarantee Trust Life Lump Sum Cancer/Heart Attack and Stroke1. Each person must be a U.S. citizen or hold a “green card” (permanent resident of US). 2. The agent must be health licensed and use the state approved application in the state where the applicant 3. If both spouses’ apply for coverage, each person must answer the questions and sign the application. 4. If power of attorney is u