materials/medical-authorization.tex at master · dshapiroww/materials · GitHub

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
\documentclass{ross}
\title{Medical Authorization}

\begin{document}
\maketitle

\textsc{Instructions:} Type the information where indicated here, then print this doeument and write in the medical information requested. Then scan that paper copy as a PDF file, and email it to$\;$ \texttt{medical@rossprogram.org}.


During the \the\year\ Ross Program, I, \blank{3in}{parent/guardian name}{parent.name}, can be reached at \blank{2in}{phone number}{phone.number}.

My medical insurance is provided by \blank{2in}{insurance company}{insurance.company} and they can be reached by phone at \blank{2in}{insurance phone number}{insurance.phone.number}.

The policy holder's name is \blank{2in}{policy holder}{policy.holder}, born on \blank{1in}{birthday}{dob}.

My medical insurance policy number is \blank{1in}{policy number}{policy.number}.

My group number is \blank{1in}{group number}{group.number} with name \blank{1.5in}{group name}{group.name}.

\vspace{1ex}

Describe below any medical conditions or concerns,
dietary/seasonal/medical allergies, non-allergy dietary restrictions,
and disability accommodations of which we should be aware:

\pagebreak

I understand that certain prescription medications are considered to
be ``controlled substances'' and require dispensation by a medical
professional. I also understand that I may authorize my child to
self-administer certain other medications, and/or I may authorize the
Ross Mathematics Program counselors to administer certain other
medications.


\blank{2in}{student name}{name} will be bringing the following prescription medications:

\vspace{0.7in}

And the following non-prescription medications:

\vspace{0.7in}

I authorize my child to \ldots \\
self-administer the \phantom{non-}prescription medications listed:  \yesblanknoblank{child.prescription} \\
self-administer the non-prescription medications listed:  \yesblanknoblank{child.nonprescription} \\

I authorize the Ross Math Program counselors\ldots\\
to administer the \phantom{non-}prescription medications listed:  \yesblanknoblank{counselor.prescription} \\
to administer the non-prescription medications listed:  \yesblanknoblank{counselor.nonprescription} \\

In the event that my child experiences a headache, fever, nausea,
sunburn, muscle pain, or other minor ailment and has not brought with
them an appropriate medication to treat such ailment, I authorize the
Ross Mathematics Program counselors to administer the following
non-prescription medications to my child:

  Acetaminophen (Tylenol):  \yesblanknoblank{tylenol} \\
  Aspirin:  \yesblanknoblank{aspirin} \\
Ibuprofen (Advil):  \yesblanknoblank{advil}  \\ Naproxen (Aleve):   \yesblanknoblank{aleve} \\
Calcium Carbonate (Tums):  \yesblanknoblank{tums} \\
Bismuth Subsalicylate (Pepto-Bismol):  \yesblanknoblank{pepto}  \\
Calamine Lotion:  \yesblanknoblank{calamine} \\ Sunscreen:   \yesblanknoblank{sunscreen} \\

\vspace{0.25in}
Signed \rule{3in}{.1mm}  on this  \blank{1in}{Date}{date}\\[-5pt]
\hspace*{1in}{\footnotesize \textcolor{gray}{Parent or legal guardian} }

%\blank{3in}{Parent or legal guardian}{parent.name} on this \blank{1in}{Date}{date}


\end{document}


%%% Local Variables:
%%% mode: latex
%%% TeX-master: t
%%% End: