2022 SH Mission Trip Medication & Emergency Consent Form

Student Name

Address

Student Date of Birth:

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Name

Parent/Guardian Phone

List any know allergies/reactions

Please state any health issues we should be aware of. Please list anything that might be helpful for our staff. This information will not be shared with other students. It can help us to know if your student has anxiety, ADD, any other kind of behavioral issues, any past surgeries, etc.

Please list any allergies; food, insect bites, medicine, environmental, etc.

Please list any prescribed or over-the-counter medications your child is currently taking. All medication, excluding inhalers, contraceptives, epi-pens and topical creams, must be taken while administered by a member of our Mission Trip Adult Leadership Team.

Name of Medication

Dosage/Route

Times

Name of Medication

Dosage/Route

Times

Name of Medication

Times

Dosage/Route

Names of Medication

Dosage/Route

Times

Parent/Guardian Self-Carry Authorization

For Epinephrine Autoinjector: As the parent/guardian of this student, I authorize my child to possess and use an epinephrine autoinjector, as prescribed. I understand that an Avon Lake U.C.C staff member, chaperon or volunteer will immediately request assistance from an emergency medical service provider if this medication is administered. I will provide a backup dose of the medication to the Director of Youth Ministries or designated Medication person for the trip. YES NO

For Asthma Rescue Inhaler: As the parent/guardian of this student, I authorize my child to possess and use an asthma rescue inhaler as prescribed. YES NO

For oral contraceptives: As the parent/guardian of this student, I authorize my daughter to possess and take her oral contraceptives as prescribed. YES NO

Medication Procedures

1. All medications must include the original Rx or OTC bottle with complete directions. If a weekly pill reminder box is utilized, it must have the student’s name on it, and the original pill bottles must still be sent with it. All Medication, prescription & over the counter must be kept locked up with the designated Medication Person attending the trip. Please pack only the amount of medication needed for the trip. Put all Rx and OTC medications for each individual in a large clear Ziploc labeled with the student’s name.

2. If the student carries medicine without meeting the above criteria, the medication will be taken from the student and the student will be subject to disciplinary actions and possibly removal from the trip, sent home at the parent’s expense.

3. The chaperones on this trip have permission to take my child to a hospital or medical facility for emergency medical or dental treatment.

CONSENT:
I hereby agree to hold the Avon Lake United Church of Christ, the Director of Youth Ministries, Adult Volunteers, staff and any other chaperones harmless for any accident that may occur during the trip.

Parent Signature

Date

Over The Counter Medications

My child can be administered the following OTC medications in the recommended dosage, on the advice of adult mission trip staff, in the event of minor symptoms: Ibuprofen (Motrin), Acetaminophen (Tylenol), Diphenhydramine (Benadryl), Loratadine (Claritin), Hydrocortisone Cream (Cortaid), Triple Antibiotic Ointment, Generic Tums or Rolaids, loperamide (Imodium), Dimenhydrinate (Dramamine)

I agree I do not consent

Insurance Information

Please upload the front and back of your insurance card.

Front of card

Upload (8MB)

Back of card

Upload (8MB)

Insurance Company

Contract/Policy #

Policy Name Holder

Description

This form is to be completed by all students attending our 2022 SH Mission Trip.

2022 SH Mission Trip Medication & Emergency Consent Form

Description

Please Fix the Following