Upward Bound Program
3301 N. Mulford Rd. Rockford, IL 61114-5699 (815) 921-4235
PARENT CONSENT FOR PARTICIPATION AUTHORIZATION FOR MEDICAL ATTENTION
The undersigned does hereby give permission for, our (my) child to attend and participate in the activities sponsored by the Rock Valley College Upward Bound Program, to ride any vehicle designated by the UB Program Staff in whose care the minor has been entrusted while attending and/or participating in program activities. I agree not to hold the Upward Bound Program, its staff, or Rock Valley College liable for any loss or injury that may occur during my child’s participation in Upward Bound activities. I understand that while my son/daughter is an Upward Bound participant, he/she will participate in a variety of academic, cultural enrichment and recreational activities. My son/daughter will abide by the rules and regulations stipulated by the RVC Upward Bound Program, Administration and Staff, and is subject to dismissal from the Upward Bound program if these rules are violated. TO MEDICAL PERSONNEL
We (I) authorize the adult, in whose care the minor has been entrusted to consent to any X-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provision of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Hospital Insurance?
List all allergies or special medical problems that your child may have
Rock Valley College Upward Bound STUDENT EMERGENCY MEDICAL TREATMENT CONSENT FORM
The purpose of this form is to enable minor students and adult students to receive emergency medical or dental treatment should they become ill or injured on this trip and under the authority of Rock Valley College Upward Bound and their parents or legal guardians cannot be reached. Please read the section that follows and print and sign your name on the appropriate lines below. In the event reasonable attempts to contact
Parent/Guardian Name (Print)/Emergency Contact Person
have been unsuccessful, I give my consent for
to receive any treatment deemed necessary by a licensed medical doctor or dentist and the transfer of the student to a hospital in the area of this trip. This authorization does not cover major surgery unless the medical opinions of at least two other licensed medical doctors or dentists, agreeing on the necessity for such surgery, are obtained prior to the performance of such surgery. Please provide information concerning the student’s medical history and describe any physical impairments or conditions (including any allergies) requiring the use of medications and to which physicians should be alerted. Also, please list any medications currently used by the student that will be brought on the trip. My student has these medical conditions:
My student has no medical conditions. My student takes the following medications: Medication(s) Dose/Frequency
Please review the list of over-the-counter medications below and check the ones that you permit your
child to be given during Upward Bound program activities. If a preferred medication is not listed,
please write it on one of the blank lines. If you do not want the Upward Bound program to administer
any over-the-counter medicines, please indicate.
I do not authorize Upward Bound to give my student any over-the-counter medicines.
I authorize the Upward Bound program to administer the following over-the-counter medicines as indicated below.
Loratadine (Antihistamine) (Non Drowsy)
______Benadryl – (Diphenhydramine) (Drowsiness) Other (Explain)
GASTROENTEROLOGY CONSULTANTS MiraLax/Gatorade iNStrUCtioNS For CoLoNoSCoPY Your appointment is scheduled on ________________________at ______________AM PM with Dr. _____________________. Be at the location marked below by _________________AM PMA. Five days prior to the procedure stop herbals, vitamins, iron pills, blood thinners, stool formers such as Imodium, and fiber supplements (th
Publikationen Prof. Dr. med. Stephan Miehlke 2013 Miehlke S , Madisch A, Kupcinskas L, Petrauskas D, Heptner G, Böhm G, Dr. (5), Marks HJ, Neumeyer M, Nathan T, Fernández-Bañares F, Greinwald R, Mohrbacher R, Vieth M, Bonderup OK. Randomized, Placebo-controlled Multicenter Study of Budesonide and Mesalamine for Short-term Treatment of Collagenous Colitis. JAMA 2013, eingereicht Miehlke