Microsoft word - grade 11 wv 2011 arch medical & extendedfieldtrip form

Extended Field Trip – Long Form
Name of Son/Daughter/Ward: _________________________________________________ Parish/School: St. Anthony on the Lake, Pewaukee, WI .
Designated Supervisor of Activity: Ann Fons .
Activity: Mission Trip To Mingo County West Virginia
Description of Activity: Service with YouthWorks in Lincoln County West Virginia
Date(s) and Time of Activity: July 16 – July 24, 2011
Method of Transportation: Rental Vehicles driven by volunteer chaperones
Student Cost (If Applicable): $375 fee plus $135 in shares sold
Paperwork Deadline: March 20, 2011
I consent to the participation of my SON/DAUGHTER/WARD in the above named ACTIVITY. In consideration for my SON/DAUGHTER/WARD’s participation, I agree to reimburse and indemnify the PARISH/SCHOOL (understood to include the Archdiocese of Milwaukee) for all reasonable legal and court fees incurred by PARISH/SCHOOL in defending a lawsuit that I or my SON/DAUGHTER/WARD may bring against the PARISH/SCHOOL which relates to the above named ACTIVITY if the PARISH/SCHOOL is found not legally liable by the courts and prevails in the lawsuit. If the PARISH/SCHOOL is found legally liable for injuries sustained by SON/DAUGHTER/WARD, this paragraph will not apply. I certify that I have an understanding of this agreement and any risks and hazards associated with the ACTIVITY described above that my SON/DAUGHTER/WARD will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the PARISH/SCHOOL to clarify any concerns of questions about the ACTIVITY or this agreement that I may have had. PARENT/GUARDIAN’S NAME(S): ______________________________________________ HOME ADDRESS: ____________________________________________________________ HOME PHONE: (____)___________________ BUSINESS PHONE (____) ______________ Signature__________________________________________ Date ______________________ OPTIONAL: If different from above or reverse side:
OTHER PARENT/GUARDIAN’S NAME: _____________________________________ OTHER HOME ADDRESS: _________________________________________________ HOME PHONE: (____)______________ BUSINESS PHONE (____) ______________ The other side of this form must be filled out and signed.

PARTICIPANT’S NAME:________________________ BIRTH DATE: ____________ SEX: ____________
FAMILY DOCTOR: ____________________________ PHONE: (____)_____________________________ Family Health Plan Carrier: _______________________ Policy Number: ____________________________ MEDICAL MATTERS: I hereby warrant to the best of my knowledge, my child is in good health, and I
assume all responsibility for the health of my child. OF THE FOLLOWING STATEMENTS pertaining to

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child
to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact: NAME & RELATIONSHIP: ________________________________________________________________ HOME PHONE: (____)_____________________ BUSINESS PHONE: (____)________________________ Signature ____________________________________________ Date _______________________________ Other Medical Treatment: In the event it comes to the attention of DESIGNATED SUPERVISOR or
staff that SON/DAUGHTER/WARD becomes ill with symptoms of headache, vomiting, sore throat, fever, or diarrhea, I DO want to be called collect (with phone charges reversed to myself in necessary). Signature ____________________________________________ Date _______________________________ Medications: SON/DAUGHTER/WARD is taking medications at present and will bring all such medications
necessary, and such medications will be well-labeled. I give permission for SON/DAUGHTER/WARD to take this medication on his/her own. The dosage and frequency of dosage is as follows: ________________________________________________________________________________________ Signature ____________________________________________ Date _______________________________ If requested, I DO give permission for SON/DAUGHTER/WARD to be given the following (circle):
Signature ____________________________________________ Date ___________________________ No Medication of Any Type: whether prescription or nonprescription may be administered to my
SON/DAUGHTER/WARD unless the situation is life threatening and emergency treatment is required. Signature ____________________________________________ Date ___________________________ Specific Medical Information: The parish/school will take reasonable care to see that the following
information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.): ________________________________________ Immunizations: Date of last tetanus/diphtheria immunization: _______________________________________ Does child have a medically prescribed diet? ____________________________________________________ Any physical limitations? ___________________________________________________________________ Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking bedwetting, fainting? _____________________________________________________________________________ Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so date and disease or condition: ____________________________________________________________ You should be aware to these special medical conditions of my child: ________________________________ ___ _____________________________________________________________________________________ Form: 6153(d) 5-1-01


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Curriculum vitae

Curriculum Vitae Michael Ristow , M.D., born April 24th, 1967 in Lübeck, Germany Education and Positions Held 1973 – 1977 Luther Elementary School, Lübeck 1977 – 1986 St. Johanneum High School, Lübeck 1986 – 1992 University of Bochum Medical School 1986 - 1992 Stipend Recipient (Studienstiftung des Deutschen Volkes) 1991 – 1992 Internships (Anesthesiology, Internal Med.

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