Medication Information. You may disregard this section if none of the children you are registering for VBS are currently taking any medication. Medications: My child/children is/are taking medication at present. My child/children will bring all such medications necessary and such medications will be well-labeled. Please clearly indicate names of medications and concise directions for seeing that the child/children takes such medications, including dosage and frequency of dosage, and which child is taking which medication are as follows: As Parent or Guardian, I agree to all of the above/previously stated considerations and conditions. Signature: Date: AUTHORIZATION, CONSENT AND RELEASE FOR USE OF VISUAL LIKENESSES AND ORIGINAL WORKS OF MINORS This form allows you, the parent or guardian, to identify if images of your child/children and their original works may be used for purposes of print, online, social media communication and promotion. I am the parent or legal guardian of (full name of minor(s) participating in VBS (“My Child/Children”). I grant the following rights to St. Xxxxxxx’s Catholic Community and the Archdiocese of Saint Xxxx and Minneapolis:
Medication Information. Number of medications needed during service contract: Name of Medication (only enter one medication here): _ Amount Given: (For additional medications, please fill out addition medication information on the next sheet starting with #2) Time to Administer: Give meds times for days. Reason for Medication: Known side effects: Instructions for administration: Has pet been on this medication before: □ Yes □ No Any known problems with administering: □ Yes □ No Please Describe: Policies and Procedures The client agrees to the following:
Medication Information. Allergies: Allergic to What Reaction Current Medications: Medication Strength Medication Strength Herbal/Over-the-Counter/Nutritional Products: Product Taken How Often Product Taken How Often Diseases/Conditions Disease/Condition Year Diagnosed Disease/Condition Year Diagnosed *Please provide your prescription insurance card before we fill your prescription PHOTO CONSENT I freely give my consent to have my picture taken and be used by Xxxxxx’x Pharmacy and Home Medical for my patient file. Printed Name: _ Signature: Date: Witness: Defiance • 0000 Xxxx Xxxxxx Xxxxxx, Xxxxxxxx, XX 00000 • (000) 000-0000 • Fax (000) 000-0000 Continental • P.O. Box 388, Continental, OH 45831 • (000) 000-0000 • Fax (000) 000-0000 Lab Work Levels of hormones can be helpful in evaluating your replacement needs. We suggest that you have your physician get base line levels of your hormones before starting human bio-identical hormone replacement. Levels can be checked by either blood or saliva sample. If you prefer to have saliva testing, please contact the pharmacy for a saliva kit. Blood levels will have to be drawn at your physician’s office. The following labs are what we suggest you have drawn or collected: Males: Testosterone Free DHEA-sulfate SHBG Estradiol LH PSA Cortisol—4 point (If under a lot of stress) Thyroid (T4 total and free, T3 total and free, TSH, Vit D 25, Vit D 25 OH, Ferritin) (if tired, constipated, cold blooded, depressed, or experiencing weight gain)
Medication Information. Allergies: Allergic to What Reaction Current Medications: Medication Strength Medication Strength Herbal/Over-the-Counter/Nutritional Products: Product Taken How Often Product Taken How Often Diseases/Conditions Disease/Condition Year Diagnosed Disease/Condition Year Diagnosed *Please provide your prescription insurance card before we fill your prescription ADRENAL QUESTIONAIRE If you answer yes to 3 or more of these questions, you may have some degree of adrenal burnout: Are you tired for “no reason”? Do you have trouble getting up in the morning? Do you need coffee or colas to keep you going? Do you feel run down and stressed? Do you crave salty or sweet snacks? Are you struggling to keep up with life’s daily demands? Can you not bounce back from stress or illness? Are you not having fun anymore? Is your sex drive decreased? Do you have difficulty falling/staying asleep or do you have trouble shutting your mind off at night? Do you have vivid nightmares or dreams? Do you have low blood pressure (lower than 110 on the top and lower than 70 on the bottom)? Do you feel as if you could take a nap an hour or so after lunch? Do you eat at least one processed or sweetened food at each meal or frequently skip meals? Are your pupils normally dilated even during the day? Do you seem to get sick or suffer from allergies more frequently than you used to? Do you feel pressured or rushed often during the day? Do you experience lightheadedness, mood swings or headaches if you go more than 4-6 hours between meals? MEMORY QUESTIONAIRE Over the last year, I have experienced: Becoming forgetful Lapses in memory Becoming less attentive Less interest in normal activities Feeling less sharp Difficulty remembering people’s names Difficulty making decisions Problems finding the right words to communicate Difficulty solving routine problems Difficulty learning new things Problems writing, reading, or organizing thoughts Difficulty following instructions Amino Acid Deficiency Symptoms Instructions: Mark the box or boxes that identify your corresponding symptoms. L-glutamine Cravings for sugar, starch, or alcohol Reduced mental stability L-tyrosine, L-phenylalanine Depression Lack of energy Lack of drive Lack of focus, concentration GABA Stiff and tense muscles Stressed Feeling “burned out” Unable to relax DL-phenylalanine, D-phenylalanine Very sensitive to emotional or physical pain Cry easily Crave comfort, reward, or numbing treats “Love” certain foo...
Medication Information. Allergies: Allergic to What Reaction Current Medications: Medication Strength Medication Strength Herbal/Over-the-Counter/Nutritional Products: Product Taken How Often Product Taken How Often Diseases/Conditions Disease/Condition Year Diagnosed Disease/Condition Year Diagnosed *Please provide your prescription insurance card before we fill your prescription
Medication Information. While on a GDS overnight activity, and recognizing that students may at times be out of a chaperone’s supervision (i.e during a homestay), students are allowed to self-medicate. For all prescription medications that a student takes, a Medication Action Plan is required. Please note that a Medication Action Plan must be signed by both the student’s health provider and parent/guardian. Students medicating with a prescribed drug may carry only the dosage sufficient to last for the duration of the trip. Medication should be carried in a standard pharmaceutical container and must be properly labeled with student name, medication name, dose and directions for administration. (Should you, as parents/guardians, prefer that your child not self-medicate, please contact the trip chaperone and school nurse to discuss whether we can accommodate your request.) Because school personnel may not provide students with any over-the-counter medication, students are permitted to possess and use common headache, antihistamine, and anti-diarrhea medications when they are listed below. As with prescribed drugs, students may carry only the dosage needed for the trip and may do so only in a properly labeled container. Under no circumstances are students permitted to give or sell any prescription or nonprescription, over-the-counter or other drug to another student. Violation of this rule may subject a student to disciplinary action. If your child takes medicine on an emergency or regular basis, please indicate such on this form. We must be notified of any and all prescription and over-the-counter medication brought on the trip. This includes inhalers and epinephrine auto-injectors. Students carrying emergency medication such as inhalers and epinephrine auto-injectors should inform the chaperones where these are stored in case they are needed in an emergency. will be bringing the following Prescription Medications: **must also complete a Medication Action Plan for each medication listed below Name of Medication Dosage and Time Reason Note Over the Counter Medications (does not require a Medication Action Plan): Name of Medication Dosage and Time Reason Note SIGNATURE OF PARENT/GUARDIAN Date
Medication Information. Prescription medication can be administered by staff with written permission from parents/guardians. Children are not to carry medication in their bags. Please note that any medication not in the original container and clearly labeled with the child’s name and dosage WILL NOT BE ADMINISTERED. All children requiring medications must fill out a Medical Information sheet upon enrolment to our Centre. Buzi Kidz OOSH welcomes children with additional needs. However, before enrolment we do require detailed information about your child’s individual needs. If your child has high support needs, additional support may be required via the Commonwealth Government’s Inclusion Support Subsidy (ISS). Contact us as soon as possible on 0421785545 Communication and Parent Involvement At our Centre we encourage positive and open communication between all parties involved. Communication between Parents and Staff is crucial to the everyday running of the Centre. The Centre will communicate with Parents and Carers through newsletters, notices, emails, and general verbal communication. Parents are always welcome at our Centre to watch or play with their children. We understand how busy families are but we do encourage your input and participation where possible. Please feel free to comment or give feedback within all areas of the service.
