medical-authorization.tex

\documentclass{ross}
\title{Medical Authorization}

\begin{document}
\maketitle

\textsc{Instructions:} Type the information where indicated here, 
then print this document 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}, 
the parent/guardian of \blank{2in}{student name}{name} (the ``Participant''), 
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}.

I understand that every reasonable effort will be made to contact me
at the contact information I have provided in the event of an
emergency.  In the event that I cannot be located immediately, the
authorities of the Ross Mathematics Foundation may take such temporary
measures as they deem necessary.  I give permission to Central Ohio
Primary Care or other physicians selected by the Ross Mathematics
Foundation to treat, hospitalize, order injection, anesthesia, or surgery
for the Participant.  I give permission for the release of this health
information form as well as any accompanying information or medical
records to medical professionals in the event of injury or illness.

To the best of my knowledge and belief, the Participant is and has
been in normal good health and is free from all communicable or
contagious diseases. Should the Participant manifest any condition
where there appears to be reasonable grounds for suspecting the
presence of a communicable or contagious disease, I agree that a
physical examination may be performed. Also, I agree that if any such
disease is found, the Participant will comply with the regular
quarantine or isolation procedures of the camp and of the community.
I agree that the Participant will submit to surveillance testing for
COVID--19 which may include mandatory antigen or PCR tests.

\vfill

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

\pagebreak\null\vspace{-1in}

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

\vspace{0.4in}

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{0.4in}

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} }

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

\end{document}





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