Young Friend’s Name _____________________________
There may be times when your child suffers from mild symptoms that can be treated with simple
over-the-counter medications that we have available in our first aid kit.
If you give permission for your child to receive the following medications, check the yes column.
If that column is not checked, then permission is
Time and Date Given
(For use by retreat FAP)
reactions: only in severe emergencies, and
Information on Tetanus Shots
Date last shot: Don’t know______ Less than 5 years_____ 5 -10 years:_____ Over 10 years ________
Is your child is allergic to tetanus:_____ yes _____ no ________
If there is an accident for which a tetanus shot is recommended, may we authorize it? Yes_____
Does your child have asthma? Yes____ No____ If yes, please answer the following questions:Does your child use a daily medication? If yes, please list the medication(s) and the dosage(s):
How often does he/she experience an asthma attack? ________________________________________
Has your child ever been hospitalized because of asthma? ____________________________________
Is your child able to recognize and treat the onset of an attack?_________________________________
Can your child recognize when the attack is severe and requires the attention of medical professionals?
How should we respond to a breathing problem with your child?
SOUTHERN APPALACHIAN YOUNG FRIENDS (SAYF)
Young Friend: ___________________________________________________Date of Birth_________________
Parent or Legal Guardian: _____________________________________________________________________
Phone #s during the retreat (home. Work, cell, pager):____________________________________________
Emergency phone number (and name) if parent cannot be reached: _______________________________
I give permission for my minor child to attend Southern Appalachian Young Friends Retreats. In theevent of an emergency, I authorize the adult leaders of SAYF to act for me to make any and alldecisions for me concerning the medical treatment or hospitalization of my minor child; to consent toany X-Ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advisedand supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the lawsof the state where the services are rendered, either at a doctor's office or in a hospital. I specificallyrequest that an adult leader accompany my child during any evaluation and treatment to the sameextent as I would as a parent and guardian unless my child requests otherwise for reason of privacy. Iexpect to be contacted as soon as possible. I absolve the adult leaders from personal liability arisingfrom the exercise of such authority, including any and all costs, expenses, and charges for medical orhospital care provided by or received from whomsoever, and costs of transportation related thereto. Iaffirm that the following insurance and medical information is complete and correct.
Signature of Parent or Legal Guardian:____________________________________ Date_________________
Phone number_______________ Policy number_____________ Policyholder:_____________________
Family doctor (and phone number):_____________________________________________________________
Prescriptions currently taken (please keep usup-to-date!):__________________________________________________________________________________
Current medical or psychological conditions, allergies, etc ________________________________________
Other information that adult leaders and/or emergency room physician should know: _______________
PLEASE DONT FORGET TO FILL OUT PAGE 2 OF THIS FORM!
SAFETY DATA SHEET Based on Directive 2001/58/EC of the Commission of the European Communities PROGESTERONE Identification of the substance/preparation and of the company/undertaking 1.1 Identification of the substance or preparation: Synonyms: : 57-83-0 Reference number : EC index No. NFPA code : 0-1-0(*) Molecular weight Formula : 1.2 Use of th
ALCOHOLIC LIVER DISEASE (ALD) Thuy Anh Le MD Mentor: Dr. Mario Chojkier 8/10/2010 EPIDEMIOLOGY • Costs of alcohol abuse are ~$185 billion/year – related to lost productivity and MVA. • Etoh accounts for 40% deaths from cirrhosis and >30% cases of HCC in US • Accounts for 50,000 deaths annually • ALD develops in female after shorter duration of drinking and lower daily alcohol intak
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