Fillable Student Confidential Medical Information and Emergency Notification Form (Ames Laboratory)

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Student Confidential Medical Information and Emergency Notification Form (Ames Laboratory)

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The Student Confidential Medical Information and Emergency Notification Form (Ames Laboratory) form is 4 pages long and contains:

  • 2 signatures
  • 10 check-boxes
  • 80 other fields

Country of origin: US
File type: PDF

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Name ________________________________ Page 1 of 4
U.S. DEPARTMENT OF ENERGY OFFICE OF SCIENCE
2020 Regional Science Bowl - Ames, Iowa and National Science Bowl
®
Student Confidential Medical Information and Emergency Notification Form
(Please fill out the entire 4-page form)
To complete: Click on the space and type in the information requested. Once the form is complete: (1)
click “File,” then “Save As” and give it a name and save it on your computer; (2) print the completed
form; (3) parent/guardian or student (if 18) must sign it in ink or via Adobe Sign; (4) return this form
to the coach.
School________________________________________________
Name Birth Date Sex: M F
Street Address
City State Zip Code
Home Telephone (include area code):
PLEASE LIST TWO EMERGENCY CONTACTS:
Primary Contact (#1) Contact #2
Name: Name:
Phone: Phone:
Cell Phone: Cell Phone:
Relationship: Relationship:
Allergies
Yes No If Yes, specify:
Medication
Food
Environmental
Medical History (To include surgeries)
Date of Last Tetanus Shot:
Name ________________________________ Page 2 of 4
(A) Current/Recent Medical History/surgery (within the past 12 months)
(B) Previous Medical History/surgery (please include ALL medical history beyond 12 months)
Medication Information (Prescribed and Over-the-Counter Medications and Purpose)
Please follow the format listed below.
Current Prescribed Medications – PLEASE PRINT!
Medication/Dosage Purpose/Used For
(Example: Albuterol/10mg per day) (Example: Asthma)
Current Over the Counter Medications – PLEASE PRINT!
Medication Purpose/Used For
(Example: Advil/as needed) (Example: Headaches)
Name ________________________________ Page 3 of 4
Physical Limitations/Needs (Please include any assistive devices that need to be provided):
Mobility Limitations
Visual Limitations
Communications Limitations
Dietary Restrictions (vegetarian, kosher, etc.):
If you have severe dietary restrictions, please list samples of meals that you CAN eat:
Religious or Cultural concerns that may affect care: (e.g. No Blood Transfusions)
PHYSICIAN & HEALTH INSURANCE
Physician’s Name: Phone Number:
Do you have Health Insurance? YES _____ NO _____
If Yes, complete the following:
Insurance Company:
Policy Number: Phone Number:
Name ________________________________ Page 4 of 4
CONSENT TO MEDICAL CARE AND TREATMENT
Authorization to Arrange for Medical Care:
I hereby give permission to the U.S. Department of Energy, ORAU, Ames Laboratory and
Iowa State University to send my child for emergency room treatment and to call his/her
primary physician if necessary.
(Print Name of Parent or Legal Guardian)
(Print Name of Student)
Date
Signature of Parent/Legal Guardian (or Student if 18 years of age)
(Parental consent is required before a hospital’s emergency department can give medical treatment
to a minor. Every effort will be made to contact parents, but a completed consent form will expedite
treatment.)
I hereby authorize and consent to the administration of all medical and/or surgical treatment(s)
to my child by a licensed physician, nurse or hospital in the event I am not available to consult
with the attending p
hysician(s), attempts to contact me have been unsuccessful, and the
attending physician(s)
deem it advisable to proceed with such treatment(s).
(Print Name of Parent or Legal Guardian)
(Print Name of Student)
Date
Signature of Parent/Legal Guardian (or Student if 18 years of age)
For National Science Bowl® Regional Competition Use - Please upload the completed form to the
team's registration page using your coach dashboard: https://apps.orau.gov/nsb-coach/Account
OFFICIAL USE ONLY May be exempt from public release under the Freedom of Information Act (5 U.S.C. 552), exemption number and category: 6,
Personal Privacy Department of Energy Review required before public release Name/Org: Allen Wash/ORISE Date: 9/12/2018
Guidance (if applicable): CG-SS-5
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Student Confidential Medical Information and Emergency Notification Form (Ames Laboratory)

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Completed 19 July 2020

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