PYSO: China Health & Medical Forms

PITTSBURGH YOUTH SYMPHONY ORCHESTRA

CHINA TOUR 2008

Dear Tour Participants:

The purpose of these forms is to provide accurate medical information about each participant who will be traveling with the Pittsburgh Youth Symphony Orchestra to China from June 16-30, 2008.

The information on these forms will help us provide the best care possible and secure treatment in the event of an emergency. All information contained in these forms will be kept confidential and only shared with medical professionals if the need of an illness or emergency arises.

If you would like to discuss any of the information on these prior to the tour, please contact the PYSO office and we can advise you on how to contact the tour doctor, nurse, or chaperone directly.

Please complete the following forms and return the entire package to PYSO
by January 21, 2008. Incomplete forms will be returned. Mailing address is PYSO, 600 Penn Avenue, Pittsburgh, PA 15222.

PARTICIPANT HEALTH INFORMATION (everyone must complete)
To be completed by parent or guardian if student is under 18 years of age or included in
parent’s insurance.
PROVIDE COPY OF INSURANCE CARD WITH THIS FORM (Both sides)

PHYSICAL EXAM FORM (orchestra members only)
To be completed by participant’s physician. If a current (Since June 2007) physical examination form is available, please supply a copy and have your physician sign the updated form.

MEDICATION AUTHORIZATION FORM (required for orchestra – optional for others)
To be completed by parent/legal guardian. The medication portion of the form must be signed by participant’s Physician.

Since each individual health is different, we recommend that you read the following information and consult with your physician in order to determine which vaccines you and/or your child should have prior to the trip. www.cdc.gov/travel/destinationChina.aspx

We recommend you provide your physician with the name of the cities that will be visited in our itinerary: Beijing, Shanghai, Hangzhou, Shenzhen, and Hong Kong.

PARTICIPANT’S HEALTH INFORMATION FORM
(Everyone must complete)

PLEASE PROVIDE A COPY OF THE INSURANCE CARD (BOTH SIDES) WITH THIS FORM.

Participant’s Social Security number __________________________________

Physician’s Name___________________________Phone__________________

PARTICIPANT’S HEALTH NSURANCE INFORMATION
Insurance Carrier or plan name_____________________________________
Group Number_______________________________Policy Number_______________
Name of policy holder_______________________________________________
Name of employer (If group insurance_______________________________________
Social security number of policy holder ______________________________________

Does this policy cover the participant in China * YES ___ NO___
Exceptions/Comments: ___________________________________________________
*Please check with your insurance provider if the participant will be covered in China while on tour.

EMERGENCY INFORMATION
Primary emergency contact ______________________Relationship_______________
Day Phone________________________Evening Phone________________________
Cell phone___________________________

Secondary emergency contact ____________________Relationship_______________
Day Phone________________________Evening Phone________________________
Cell phone___________________________

Only for PARENT/GUARNDIAN of Orchestra Members:
PERMISSION TO PROVIDE NECESSARY TREATMENT OR EMERGENCY CARE
In the event of an emergency, I hereby give permission to the medical personnel selected by PYSO to secure and administer medical treatment, including hospitalization, to order x-rays, routine tests, to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for the participant.

PARENT/GUARDIAN SIGNATURE________________________Date________________

Use this space (or other side) to provide any additional information about the participant’s behavior and physical, emotional, or mental health about which the tour staff should be aware.
_____________________________________________________________________
_____________________________________________________________________

To be completed by Physician
Required Information from Orchestra Members Only

PHYSICALLY FIT TO TRAVEL

I have examined this individual and have found him/her physically fit to participate in the Pittsburgh Youth Symphony’s China tour from June 16-30, 2008.

I understand that the tour will follow a strenuous schedule that includes walking and sitting for long periods of time.

Comments: _______________________________________________________________

______________________________________________________________________

PHYSICIAN’S SIGNATURE__________________________________DATE________

(Physician’s Stamp)

Please also complete and sign the prescription medication section in the participant’s medication form.

PRESCTIPTION MEDICATIONS —To be signed by Physician

Required Information from Orchestra Members – Optional for All Others

_____ The participant does not take any prescription medications.

Medication : _____________________________Dose:________________
Time or circumstance of administration:_____________________________
Duration of administration: _______________________________________
Reason for administration:________________________________________
Medication side effects to be aware of:______________________________
Additional instructions:___________________________________________

PHYSICIAN’S SIGNATURE: _____________________________Date_________

______________________________________________________________________

OVER-THE-COUNTER MEDICATIONS
Over-the-counter pain relievers/medication that may be administered to participant (as needed)

____Acetaminophen (ie. Tylenol)   ____Pepto Bismal
____Aspirin    ____Ibuprofen (Pain Reliever)
____Mylanta   ____Anti-histamine/Decongestant (ie. Benadryl)

Other Over-the-Counter Meds:______________ Other:___________ Other:___________

I hereby acknowledge and grant permission to PYSO or medical personnel to administer the above marked medication (s) to the participant during the China Tour 2008.

PARENT/GUARDIAN SIGNATURE____________________________Date__________

NOTE: ALL MEDICATION MUST BE IN ORIGINAL CONTAINERS FROM PHARMACY WITH PARTICIPANT’S NAME ON IT AND MUST BE ACCOMPANIED BY THE ORIGINAL RESCRIPTION VALID FOR THE DURATION OF THE TOUR.

Participants must bring enough medication for the entire duration of the tour

_____________________________________________________________________