Extra-Curricular Emergency Medical Information Form printable pdf download

Extra-Curricular Emergency Medical Information Form

(to be turned in directly to the appropriate club advisor)

NOT PRESENT DURING BEFORE/AFTER SCHOOL PROGRAMS

THE SCHOOL NURSE IS

Activity:___________________________ Adult Supervisor _____________________________________

Student Name:___________________________________________________________________________

Address: ________________________________________ Home Phone:____________________________

Parent/Guardian Cell Phone:_____________________ Work Phone:______________________________

Parent/Guardian Cell Phone: _____________________Work Phone: _____________________________

My child has the following medical conditions that may require immediate attention during extracurricular

activities. Please check those that apply.

⁭Asthma ⁮Diabetes ⁮Seizures ⁮Severe allergy to ____________________________________________

(prescribed Epinephrine autoinjector)

⁯Other: __________________________________________________________________________________

After-school emergency action plans (please note students are responsible for carrying their own inhalers,

glucose tabs or snacks and Epinephrine auto-injectors and/or providing back-ups to the advisor):

Allergic Reaction: One or more of the following symptoms may occur after being exposed to the allergen;

difficulty breathing, wheezing, difficulty swallowing, hives/rash, itching or tingling of mouth or throat, swelling

of any body part.

Action: Assist the student in administering the auto-injector and then call 911. Staff may directly administer

the auto-injector if trained.

Asthma: Student feels short of breath, has difficulty catching their breathing, is wheezing, or complains of

feeling chest tightness.

Action Plan: If the student has their inhaler, allow them to use it. If no relief of symptoms in five (5) minutes,

call 911. If no inhaler available, call 911 immediately.

Diabetes: Low blood sugar reaction- hunger, sweaty, pallor, feels shaky, headache.

Action Plan: Allow student to drink a juice box or regular soda, or eat glucose tablets or a snack from their

emergency snack pack. Have student test their blood glucose level and record number. If no change in

symptoms in five (5) minutes - call 911 and have child repeat all of the above.

Seizure: Altered consciousness, involuntary muscle stiffness or jerking movements, drooling or foaming at the

mouth, temporary halt in breathing, loss of bladder control.

Action Plan: protect student from falling, call 911. Never put anything into the student’s mouth.

Parent/Guardian child specific instructions: ____________________________________________________

Authorization for Treatment

I hereby give permission to Masconomet appointed personnel and emergency responders to provide first aid and

emergency transportation to my child (named above) in the event of sudden illness or injury.

Parent signature: ______________________________________ Date:_________________________________

Extra-Curricular Emergency Medical Information Form