Medical-Release Form (Page 2 of 2) in pdf

Medications (continued)

Can your son/daughter be expected to take the right amount of medication at the proper time?

yes

If the answer is no, arrangements must be made with the adult in charge.

I give my child permission to administer his/her own medications:__________________________

Signature of parent/guardian

Child’s insurance carrier and policy number:___________________________________________

Name of primary insured:__________________________________________________________

Other pertinent information:________________________________________________________

______________________________________________________________________________

STATEMENT OF CONSENT

I, the undersigned, parent/legal guardian of___________________________________________, do

hereby consent to any x-ray exam, anesthetic, medical diagnosis or treatment and hospital services that

may be rendered to said minor, under the general or specific instructions of

______________________________________________________________________________

(Name of Child’s Physician) or, if unavailable, two on-call physicians at a hospital or clinic.

It is understood that this consent is given in advance of any specific diagnosis or treatment and is given to

encourage those persons who have temporary custody of my child, in my absence, and said physician to

exercise their best judgment as to the requirements of such diagnosis or said medical treatment.

This consent will remain effective on the 17

day of October 2015 until the minor child is delivered to

said persons entrusted with the care, custody and control of said minor child. I understand that any and

all medical expenses incurred are my responsibility and that there is no medical insurance coverage

provided by The Massachusetts Conference of the United Church of Christ.

Signature of parent/guardian below indicates permission for the named child to participate in the stated

event:

Children’s Program at MACUCC Super Saturday; October 17, 2015 per designated hours.

Parent/Guardian Name (please print) _____________________________________________________

Parent/Guardian Signature __________________________________________Date________________

**Please indicate below the Super Saturday Workshops you are attending so the staff will be able

to locate you in the case of emergency or questions if you cannot be reached by cell phone.

AM Workshop:

PM Workshop:

PLEASE RETURN COMPLETED FORM TO:

MACUCC, Attn: Andrea Bellarosa, One Badger Road, Framingham, MA 01702

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Medical-Release Form Page 2