• ARCTIC Emergency Medical Release & Consent for Treatment

  • Alaska Regional Career & Technical Instruction Consortium
    Required for all students traveling to an ARCTIC Intensive Week
  • Return this completed form to your CTE Career Guide before travel. No student may travel without a signed consent on file. Attach a copy of the insurance card if you have one.

  • 1. STUDENT INFORMATION

  • DATE OF BIRTH
     - -
    2 digit month, 2 digit day, 4 digit year

  • 2. PARENT / GUARDIAN & EMERGENCY CONTACTS

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 3. INSURANCE & HEALTH CARE PROVIDER

  • Format: (000) 000-0000.

  • 4. MEDICAL INFORMATION

  • List everything that applies. Write "None" where nothing applies — a blank line will be treated as incomplete and may delay the student's travel.
  • 4. MEDICAL INFORMATION List everything that applies. Write "None" where nothing applies - a blank line will be treated as incomplete and may delay the student's travel.
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  • ANAPHYLAXIS: if this student has a history of severe allergic reaction, an EpiPen must travel with the student and Section 6 must be completed.

  • 5. CONSENT FOR EMERGENCY MEDICAL TREATMENT

  • As the parent or legal guardian of the student named on this form, I give my consent for ARCTIC staff, chaperones, and school district personnel to obtain emergency medical, dental, surgical, and hospital care for my student during travel to, participation in, and travel home from the ARCTIC Intensive Week identified above. I understand that staff will make every reasonable effort to contact me before treatment is provided, and that treatment may proceed without my prior consent if I cannot be reached and a licensed medical professional determines that care is needed.

    I authorize the release of medical information on this form to treating providers, and I authorize treating providers to release information about care given to ARCTIC staff and to me. I understand that I remain financially responsible for the cost of any medical care my student receives.

    I certify that the information on this form is accurate and complete to the best of my knowledge, and I will notify ARCTIC staff in writing of any change before my student travels.
  • Consent Options
  • DATE
     - -
    2 digit month, 2 digit day, 4 digit year

  • 6. MEDICATION CONSENT & ADMINISTRATION

  • ARCTIC MEDICATION POLICY — PLEASE READ BEFORE COMPLETING THIS SECTION
    • All prescription and over-the-counter medications must be handed to ARCTIC staff on arrival at the Intensive Week. Staff store, dispense, and document all medications.
    • Students may not keep any medication in their possession — this includes vitamins, sleep aids, NyQuil, Benadryl, Tylenol, Advil, Aleve, Sudafed, and Mucinex.
    • The only exceptions a student may carry are saline eye drops or nasal spray, EpiPens, albuterol inhalers, and skin creams or ointments. These must still be listed below.
    • Staff may only dispense medication to a student whose parent or guardian has given written permission on this form, and will dispense according to the prescribed or labelled dosage.
  • Medications to be sent with the student Send every medication in its original, labelled container. Prescription labels must show the student's name, the medication, and the prescribed dose.
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  • Student self-carry authorization
    Check only what applies. These are the sole items ARCTIC permits a student to keep on their person.
  • Student self-carry authorization options
  • Over-the-counter medication — standing authorization
    Initial beside each medication ARCTIC staff may give your student as needed, at the dose on the package label. Leave blank to withhold permission.
  • Rows
  • I have listed every medication my student takes. I authorize ARCTIC staff to store and dispense these medications as described above, and to document each dose given.
  • DATE*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 7. STAFF USE ONLY — MEDICATION RECEIVED & ADMINISTRATION LOG

  • DATE / TIME RECEIVED
     - -
    2 digit month, 2 digit day, 4 digit year
  • 7. STAFF USE ONLY — MEDICATION RECEIVED & ADMINISTRATION LOG
    Rows

  • Questions about this form or the Intensive Week?
    Jerry Jones, ARCTIC Director • jjones@dgsd.us • (907) 841-0703
    Jenny York, CTE Career Guide, Alaska Gateway School District • jyork@agsd.us • (907) 209-4990
    Report any accident or injury to the ARCTIC Career Development Specialist as soon as possible. OSHA requires certain incidents to be reported within eight hours.

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