THE VILLAGE SCHOOL

FIRST AID AND EMERGENCY MEDICAL CARE

CONSENT FORM

Student’s Name: (please print)____________________________________________________        

                                                                                                Last                                                        First

Sex:   F             M                      Date of Birth: ______________________        Age: _________       Grade: _____

Guardian Name: (please print) ___________________________________________________________________________

                                                                                                Last                                                        First

Home Phone: _______________________ Work Phone: ______________________ Cell Phone: ______________________

Guardian Name: (please print) ___________________________________________________________________________

                                                                                                Last                                        First

Home Phone: _______________________ Work Phone: ______________________ Cell Phone: ______________________

Allergies: Does your child have any allergies to Food, Medication, Insects, Etc.?     YES            NO

If yes, please list: ______________________________________________________________________________________

Is this life-threatening?  YES / NO  Does your child have an Epinephrine Pen:  YES / NO  Expiration _________

Health Conditions: Has your child, currently or in the past, been diagnosed with any of the following health conditions:

List all oral or topical prescribed and over the counter medication(s) currently taken/used by your child:  ________________

____________________________________________________________________________________________________

MEDICATION ADMINISTRATION

Non-prescription Medication listed below is available in the event of injury 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 staff and agents of the school who are professionally trained in first aid to administer medication checked below to my child while on campus and/or during school-sponsored activities off campus. 

[  ] No medications may be administered   [  ] Acetaminophen (e.g. Tylenol-Children’s, Jr. & Adult Strengths) for fever or pain

[  ] Ibuprofen (e.g. Advil, Motrin) for fever or pain                [  ] Antibiotic ointment/cream (e.g. Neosporin) for cuts and scrapes

[  ] Throat Lozenges (e.g. cough drop)                                    [  ] Itch stopping cream (e.g. Calamine Lotion) for mosquito/ant bites

[  ] Diphenhydramine (Benadryl) for allergic reactions           [  ] Sterile eye wash for dirt/foreign matter in eyes

[  ] Tums for upset stomach (students 12 yrs or older)          

EMERGENCY CONTACTS

Child's Physician’s Name: __________________________________________              Phone Number: ______________________

Child's Dentist’s Name: ____________________________________________              Phone Number: ______________________

Name of Insurance Company (please provide a copy of card): _______________________ Policy #: ___________________

Emergency Contacts (If parents cannot be reached)

Name: _________________________________________ Relationship: __________________________________________

Home Phone: _______________________ Work Phone: ______________________ Cell Phone: ______________________

Do you give my permission for child to be released to this person?          YES      NO      

Name: ________________________________________ Relationship: ___________________________________________

Home Phone: _______________________ Work Phone: ______________________ Cell Phone: ______________________

Do you give my permission for child to be released to this person?          YES      NO     

Name: ________________________________________ Relationship: ___________________________________________

Home Phone: _______________________ Work Phone: ______________________ Cell Phone: ______________________

Do you give my permission for child to be released to this person?          YES      NO       

EMERGENCY RELEASE

I authorize staff/agents in the care of my child who are trained in the basics of first aid to give my child first aid when appropriate.  If, in the judgment of any staff member or agent of The Village 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 medically trained school representative or medical personnel.  I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility to secure necessary medical treatment for my child.  If the field trip is local, I prefer the following hospital: _____________________.  If the field trip is out of town, I give permission to transport to the nearest medical facility.  IN CASE OF SURGICAL EMERGENCY, I hereby give permission to hospitalize, secure treatment for, and to order injections, anesthesia, or surgery for my child.  Any directions to the contrary should be specified below.  I do hereby agree to indemnify and hold harmless The Village School and any agent acting on behalf of the school from any claim by any person whomsoever on account of such care and treatment of said student.

Signature of Parent/Guardian: ____________________________________________  Date: _______________________