MPSMA—MEDICAL RELEASE/INFORMATION FORM TODAY’S DATE:______________________________ Participant’s Name: _________________________________________ Date of Birth:____________________________ Street Address: _____________________________________________________________________________________ City:_________________________________________ State:______________ Zip Code_________________________ Emergency Contact #1_________________________________________________________________________
Relationship Phone (please designate if cell, work or home) Emergency Contact #2_______________________________________________________________________________
Relationship Phone (please designate if cell, work or home) Pertinent Past Medical History (including past hospitalizations & surgeries). (Use reverse side if needed).: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Currently under the care of a physician for: _______________________________________________________________________________________________________________ I give my permission for my son/daughter to take or be given the following over the counter medication (OTC): (Please circle all that apply) Advil/Motrin Pepto Bismol Imodium A-D Benadryl Cough Drops
Other over the counter medication and/or Herbal Medication: Please List:________________________________________________ Food & Drug Allergies (if more space is needed, please use reverse side):
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Medications my son/daughter is currently taking. Include all over the counter & Prescription medication taken regularly (use reverse side if needed). ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ My son/daughter has my permission to carry his/her own Inhalers or Epi-Pen (please check if you approve) PRIMARY INSURANCE: Policy #: ________________ Group #:_________________________ ID#: ________________ Name & Address of Insurance Company: ___________________________________________________________________ dental insurer, please put Phone # :___________________________________Policy Holder (Employer):_____________________________________ and include copies of the Employee’s Name:____________________________Relationship to student: ______________________________________
In the event of an emergency or non-emergency requiring medical treatment, I _________________________________________________, hereby grant permission for any and all medical and/or dental attention to be administered to my child,________________________________ in the event of an accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. Parent/Guardian’s Name (SIGNATURE): ______________________________________________________ Date: ____________________ Parent/Guardian’s Name (PRINT): _____________________________________________________________________________________ Phone numbers: Cell_____________________________; Home;_____________________________; Work: __________________________
LA PLATA, 27 de Julio de 2011 VISTO que esta Agencia Platense de Recaudación (APR) tiene entre sus funciones diseñar y ejecutar la política en materia de habilitaciones y permisos en aplicación de la normativa vigente en la materia, mejorando las condiciones objetivas de seguridad en la Ciudad a través del cumplimiento voluntario de la normativa vigente, la participación acti
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