Middle School & High School Student Medical Authorization 12 Authorization for Treatment Student Name* Student Grade* Name of Parent/Guardian completing form* Guardian/ Parent Email* Non-prescription medications listed below will be in the first aid bags to administer to students as appropriate: Please check any medications NOT to be given to your child by the Doctor or designated employee of ISY.medications Paracetamol/Tylenol – fever or pain Antihistamine – relief of allergy Antacid – for upset stomach Strepsil lozenges – for sore throat Eye wash – normal saline Lion Plaster – muscular pain DicloFenac Spray – muscular pain Ibuprofen – for fever or pain Calamine lotion – for mild allergy Calagel – for mild allergy Voltex cream – for sprains Motillium – Immodium – diarrhoea Electrolytes – dehydration Inhaler (Ventolin) – asthma/reactive airway Health concerns:Medication to be taken while on tournament (with written directions):(Please note medications cannot be kept by the students)Allergies: Special food considerations: Vegetarian: Other: Authorization for ParticipationPlease sign below to indicate that you have read and understood the student behavior expectations, and have completed the ‘authorization for treatment’ form. Please indicate that you give permission for your child to participate in the Tournament as below. International Schools around Yangon will participate. SEASAC Permission I give my permission for my child to attend the Tournament below. Tournament / Activity: In the event that ISY cannot contact you or your designated guardian, then I authorize an ISY Trip Leader or Administrator, under advice from the doctor, to make decisions regarding treatment and evacuation. I hereby authorize the ISY to provide, arrange for, or authorize necessary emergency medical treatment for my child. I further release, waive and agree to indemnify and hold harmless and reimburse ISY, its staff, and their successors and assigns from and against any claim which I, any other person, firm, corporation or entity may have or claim to have, known or unknown, directly or indirectly, from any losses, damages or injuries arising out of, during or in connection with my child’s participation in the field trip or the rendering of any emergency medical procedures or treatment. Guardian/ Parent Signature:*Date:* MM slash DD slash YYYY Name of Medical Insurance Policy Number Emergency contact information, if different from what I listed in the school databaseEmergency Contact Name Emergency Mobile Number