ETHS Band Medical Form
In addition to completing this form, this is a reminder to update your student's record at ETHS through the ETHS Nurse's Office and/or the ETHS Student Based Health Center.  All medications (including changes in dosage, brand, frequency, etc.) must be updated to reflect current practices at all times.  Students may not be given any over-the-counter medications as needs arise unless we have a note from a physician.  This can be done in advance (a blanket doctor's note detailing what medications and doses are permissible) or as needed through your physician or the ETHS Student Based Health Center.  All prescription medications must be administered by chaperones or staff and must be submitted to the ETHS Nurse's Office one week prior to departure for group travel.
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Email *
Section 1 - Student Information
Student First Name *
Student Last Name *
Date of Birth *
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Student Cell Phone *
Year in School (upcoming year) *
Section 2 - Emergency Contact Information
Emergency Contact - First Name *
Emergency Contact - Last Name *
Relationship to Student *
Emergency Contact Phone *
Emergency Contact Email *
Section 3 - Medical Plan Information
Medical Plan *
Medical Plan Number *
Medical Plan Group Number *
Medical Plan is subscribed in the name of: *
Section 4 - Allergies
Do you currently suffer from any allergies? *
If you answered "Yes" above, please list/describe your allergies below
Medication
Prescription Medication:
1) If a student typically takes medication at school, they are required to complete the ETHS Medication Authorization Form (https://www.eths.k12.il.us/site/default.aspx?PageType=3&ModuleInstanceID=907&ViewID=C9E0416E-F0E7-4626-AA7B-C14D59F72F85&RenderLoc=0&FlexDataID=525&PageID=436).  This needs to be updated as students have updates to their medication and dosage as long as they are a student at ETHS.
2) If a student takes prescription medication outside of school hours, they may not have completed the ETHS Medication Authorization Form and will need to do this prior to group travel (complete the form at the link above).
3) As part of group travel, students are not allowed to carry or self-administer any prescribed medication - this will be administered by an ETHS Staff Member or vetted ETHS chaperone while on the trip.  All prescription medication must be delivered to the ETHS Nurse's Office ONE WEEK prior to travel - in the original container with instructions (dosage, administration times and instructions, etc.).

Over-The-Counter Medication:
1) Students may carry ibuprofen/acetaminophen and self-administer as long as they carry this medication in the original container.  All other over-the-counter medication cannot be carried by students on the trip. 
2) ETHS Staff members or vetted ETHS chaperones can administer other over-the-counter medications (including but not limited to Benadryl, cold medicine, etc.) with a doctor's note.  This can be issued in advance (a blanket doctor's note that includes brand/make, dosage and parameters for taking it when needed) or when situations arise on a trip.
3) Students who do not have a healthcare provider, they can have a similar note issued in advance of travel if they have registered through the ETHS Student Based Health Center (https://www.eths.k12.il.us/cms/lib/IL01903927/Centricity/Domain/203/ETHS%20Health%20Center%20Registration%20Form%20-%20English.pdf)

I have read the procedures regarding prescription and over-the-counter medication above. *
Do you currently take prescribed medications for allergies?
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If you take medications for allergies, please list the names of the medications and how many times/when you take them each day
Are you allergic to any types of drugs? *
If you are allergic to any types of drugs, please list them below:
Medical Conditions
Do you currently take prescribed medication for a medical condition? *
If you answered “Yes” above, please list the names of the conditions and the medications you take along with how many times/when you take them each day:
This form will be used for emergency purposes only.  All information herein will be kept strictly confidential.  We will keep this form to use with any other trips this year.
Bee Sting Kits, Epi-pens, etc. must be indicated on medical forms, and must remain with the student at all times.
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