Vele mensen zullen het gevoel wel kennen, ze zitten aan de antibiotica, maar hebben dan een feestje penicilline antibiotica kopen Antibiotica zijn medicijnen die alleen op recept te krijgen zijn.
Iliorg.org
Illinois Rainbow Leadership Camp Health Form
ALLERGIES (please include child’s reactions)
Meds_____Food_____Contact_____Latex_____
Name ____________________________________
List:_____________________________________
_________________________________________
Birth date_________________________________
_________________________________________
Parent/Guardian____________________________
(Please bring all medications in original bottle we
Address___________________________________
must know about everything including over the
counter medications (see reverse for specific over
__________________________________________
Phone:____________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
1.________________________________________
__________________________________________
__________________________________________
__________________________________________
Home diet:_________________________________
2.________________________________________
Please list all special diet requirements (i.e.
Vegetarian, dairy intolerance, no caffeine, etc.)
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Diabetes_____Epilepsy/seizures______HTN_____
Cardiac______LungDisease______Asthma______
__________________________________________
Renal Disease______Cancer______Ulcers_______
Thyroid___Chickenpox____Measles/Mumps_____
Swimmer’s ear_________Ear infections_________
Policy Number:_____________________________
Cold/Cough/Sore Throat (last 2 weeks)__________ Pertinent family history______________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
health history is correct so far as I know, and the person herein described has permission to engage in all camp activities,
__________________________________________
except as noted by me. I understand that the Illinois Rainbow
__________________________________________
Leadership Camp staff includes a Registered Nurse and
__________________________________________
Certified First-Aiders who will give care for usual & common
medical issues and refer to the doctor on call as needed,
SIGNATURE:______________________________
DATE:____________________________________
PLEASE COMPLETE REVERSE SIDE OF THE FORM Illinois Rainbow Leadership Camp Health Form
The Illinois Rainbow Leadership Camp Nurse, Stacy Newton, RN, BSN, has my permission, should the need arise, to administer the following over the counter medications to my child, ________________________, (note, generic brand medications will be given): ___ Acetaminophen (Tylenol)
Signed: _______________________________, Parent / Legal Guardian Date: ____/____/____. The following OPTIONAL Emergency Authorization is suggested by BroMenn Medical Center, Normal, Illinois (the hospital closest to Camp)
AUTHORIZATION FOR EMERGENCY MEDICAL AND/OR SURGICAL TREATMENT FOR A MINOR
CHILD AND DESIGNATION OF PERSON AUTHORIZED TO GIVE SUBSTITUTE CONSENT FOR
KNOW ALL MEN BY THESE PRESENTS that I (we), of (city) ________________________, In the County of _____________________ and State of Illinois, do hereby direct BroMenn Healthcare to accept the consent of Stacy Newton R.N.,BSN, Illinois Rainbow Leadership Camp Nurse, an adult, for any and all medical treatment which may be needed by my child, __________________________________, when I (we) am (are) unavailable and efforts to contact me (us) are unsuccessful. I hereby authorize Stacy Newton R.N., BSN, Illinois Rainbow Leadership Camp Nurse, to make any and all necessary health care decisions on behalf of my child which my be required during my daughter’s attendance at Illinois Rainbow Leadership Camp, June 21-27, 2009. _______________________________________________ DATE_______________________ SIGNATURE OF PARENT/GUARDIAN
WITNESS OR NOTARY
_______________________________________________ DATE_______________________ SIGNATURE OF WITNESS OR NOTARY __________________________________________ Relationship of Witness OR Notary Stamp
January 28, 2013 Roll Cal : Present Stacy Ross, Ted Disabato, Brenda Smarko, Jan Hil , Kendal Dauphin, Beth Murphy Reports: Peggy Meyer – Principal of Woerner School Update: Woerner has 400 students, preschool – 5th grade; pul students from Holly Hil s, Bevo; Feed to Long and Blow Schools; Feel free to cal for a visit; 85% of students on free or reduced lunch; Woerner has single gend
5. Phillips EJ, Keystone JS, Kain KC. Failure by early 2006, only sporadic cases obtained from the health and market of combined chloroquine and high-dose were found. In July 2006, an outbreak authorities. Oral consent for interview primaquine therapy for Plasmodium vivax malaria acquired in Guyana, South Amer-of HPAI was confi rmed on 2 chicken was obtained from participants. ica. Clin In