Medical Treatment Authorization Form

MEDICAL TREATMENT

AUTHORIZATION FORM

Name of Child (please print)

Date of Birth

Address

City _________________________ State ________ Zip _____________ Phone

Print the names of parent(s) and/or legal guardian(s):

Name of Program to be attended

Medical History

Does the child have any known physical defect or illness which might interfere with his/her

participation in strenuous activity? If so, please explain.

Does the child have any allergies or reactions to drugs or medicines? Explain.

Does the child have any other allergies? Explain.

Is the child presently taking any medications or on any special diet or exercise restrictions? If

yes, please list specific details (name of drugs, dosage, etc.).

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Are there any emotional/social disabilities that would be helpful for us to be aware of?

Is your son/daughter living with both parents one parent guardian other

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Parent category: Business