Cat medical form

Part 1: This section should be filled in by parent or legal guardian. Please type or print plainly. Student’s Name: ________________________________________________________________________ Home Address: _____________________________________________________________________________________________________ ____________________________________________________ (Father) ______________________________ ____________________________________________________ (Mother) ______________________________ Home telephone: _________________________ Occupation: Who is the custodial parent of student: Both Mother Father Other ______________________________ Medical Insurance No If Parent not available in Emergency Contact: __________________________________________ Relationship to Student: ___________________________________ Parents: Please read and affix signature and date: This is to authorise the staff of the summer session site and/or emergency physicians (and any consultants that they deem necessary) of nearby (or the most appropriate) hospital to render necessary first aid/medical care to my child (name of child) _____________________________. However, in the event of an emergency, if I cannot be reached, or the person designated above cannot be reached, I consent for the Health Centre staff of the summer session site, physicians on the active staff of the nearby (or the most appropriate) hospital, or another physician or hospital (as the case may be) to perform any emergency treatment including surgery, requiring the use of local or general anaesthetic. This authorisation shall be in effect as long as my child is a student in the CAT 2011 Summer Programme. Furthermore, I the undersigned will assume full responsibility for all medical costs incurred by my child not covered by medical insurance or normally provided without charge by the Health Centre of the summer session site as part of the 2011 CAT Summer Programme. _________________________________ ___________________________________________ If there are any details of the items from the above checklist that a person acting in loco parentis or a person involved in the student’s care or treatment should be made aware of, please include them below. _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Is your child under the care of a psychologist, psychiatrist, or counsellor? If so please provide name: _________________________________ Has your child received treatment for behaviour issues? Please include details below. __________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ If there are any physical activities in which you would not wish the student to participate, please indicate these below (include reasons) _______________________________________________________________________________________________ _______________________________________________________________________________________________ Any student taking medication during the Programme (even if self-administering) MUST be brought to the attention of the CTYI/CAT Director. Please note CTYI/CAT will not be held responsible for non-disclosure of any medical condition. TREATMENT - Give full details of any medical treatment, prescribed by any doctor, to be administered during the Semester. __________________________________________________________________________________________________ __________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ DOCTOR: Name: _____________________________________ ______________________________________________________________ ___________________________________________ CTYI/CAT will supply the following medications (or their generic equivalents) as needed for the symptoms indicated, and according to package directions. Tick off those medications that your child can receive on an as-needed basis. Does your child carry an EpiPen for Allergies? Allergies to medications, food, insect bites, environmental factors etc: Other: please indicate: __________________ Families are responsible for the costs of prescriptions and transport costs to and from medical centres and any health care beyond that provided free of charge on campus. Please note that these costs must be paid for immediately. Please provide a credit card / laser card number that wil al ow CTYI/CAT to charge you for these expenses. Please note that CTYI/CAT wil contact you prior to charging this card. If you do not have a credit card CTY/CATI wil contact you before any basic medical treatment. ___________________________________________________________ _____________ - _____________ - _____________ - _______________

Source: http://www3.dcu.ie/ctyi/pdf/CAT%20Medical%20Form.pdf