China medical form

Medical Procedures and Relevant Information
1. Parents and participants should inform us of pertinent health-related information on the MEDICAL INFORMATION AND PERMISSION FOR MEDICAL TREATMENT FORM. 2. If parents wil be traveling while their son is in China, we need to know how they can be reached in case of emergency. Please enter the relevant information on the MEDICAL INFORMATION AND PERMISSION FOR MEDICAL TREATMENT FORM. 3. Please note that winter travel to China does not require immunizations. 4. Any over-the-counter or prescription medications brought by trip participants must be listed on the form provided. Chaperones must know what they are, their purpose, and dosing details. This information should be entered in the MEDICAL INFORMATION AND PERMISSION FOR MEDICAL TREATMENT FORM. 5. Each chaperone wil carry a smal medical kit with basic over-the-counter medications (see medication list). Participants DO NOT need to pack these medications. 6. Parents must sign the release form on the MEDICAL INFORMATION AND PERMISSION FOR MEDICAL TREATMENT FORM al owing chaperones to dispense over-the-counter medications and prescriptions for their child. 7. Participants with inhalers and/or epi-pens wil carry one with them at al times. Chaperones wil carry back-up epi-pens at al times. 8. In case of an emergency, chaperones wil use their best judgment to obtain the proper medical treatment for the participant. In al situations requiring major medical decisions, chaperones wil make every effort to contact both the parents and pediatricians before carrying out the treatments. 9. If necessary, we wil employ the best facilities that cater to foreigners in al medical situations. 10. Untreated water (in China, al water has to be treated), unwashed fruits, and unwashed vegetables are not safe to consume. Most hotels boil and filter water, but we wil be drinking bottled water during our entire stay in China. We wil never be eating street food or drinking tap water. 11. Check your medical insurance in terms of coverage for il ness occurring overseas. The cost of minor medical services, in most cases, is minimal and covered by Crystal Asian Adventures. For other more serious cases, medical costs wil be the responsibility of the parents. Please consider buying additional travel insurance if deemed necessary. If you have not done so already, we highly recommend travel insurance. MEDICAL INFORMATION AND PERMISSION FOR MEDICAL TREATMENT FORM

Student Name: ______________________________
PART 1: Please answer the fol owing to the best of your knowledge (consult your
physician if necessary).
a) Please list any known al ergies for your child:
b) Please leave blank if your son is not on medication. My child is presently on the
fol owing medications and wil need to take the fol owing medications while on the trip:
Medication: ________________________ Dose: _________________
Medication: ________________________ Dose: _________________
Medication: ________________________ Dose: _________________
Medication: ________________________ Dose: _________________
Medication: ________________________ Dose: _________________
c) List al major and minor medical issues that the chaperones should know about your
son (e.g., motion-sickness, seizures, etc.):
d) Please list al special dietary requirements:
e) Please specify restrictions on physical activities:
f) Please indicate any over-the-counter medication that you do not want the
chaperones to dispense to your child (please refer to the list of medications that the
chaperones wil bring on the trip):
PART 2: Please initial next to the fol owing statements to acknowledge your consent.
a) My child is in good health and may participate ful y in al planned activities (unless
otherwise noted in PART 1). ______
b) In case of a medical emergency arising during my child's trip, the trip chaperones are authorized to take him to a doctor or hospital for treatment. (Chaperones wil make every effort to contact parents should any problems arise.) ______ c) I give permission for the chaperones to dispense over-the-counter medication as needed (unless otherwise noted in PART 1). ______ d) Although there is no requirement for immunization for this trip, I understand that it has been recommended to me to check with my child’s pediatrician to ensure that my child is up-to-date on necessary protections against diseases such as Tetanus, Polio, MMR, Typhoid, and Hepatitis. ______ Signature of parent/guardian ____________________ Date: __________________ If parents will be away from home during any part of our trip, please enter contact
information below.

In the event that parents cannot be reached, who should be contacted? Please include name, relationship, and contact information for these individuals. Please feel free to use the back of this page if more room is needed. FIRST AID KIT - MEDICATION LIST

Trade Name Usual
Ace bandages
Sterile gauze pads
Adhesive tape
Plastic gloves
Alcohol pads
Hydrogen Peroxide
While the trip organizers wil include these items in their first aid packages, it is wise for
individual participants to pack smal personal first aid necessities that he may be using
prior to the trip or on a regular basis (ie, band-aids, cough drops, antacid tablets, etc.).
** If your son has asthma, please have him bring his own inhalers. We wil not carry
any in our first-aid kit.


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