Diocese Of Boise Youth Permission & Medical Release Form (Page 2 of 2) in pdf

Diocese of Boise Youth Permisson and Medical Release Form

(cont.)

Please check which applies.

___ I am covered by hospitilization and medical insurance under policy #: _________________________________

issued by _________________________________________ . The subscriber’s name is

________________________________. The family physican is __________________________________

and he/she can be reached at # _________________________.

Medical Treatment Preferences

Medications: My child is taking medications at present during this event. My child will bring all such medications necessary,

and such medications will be well-labeled. Names of medications and concise direction for seeing that the child takes such

medications, including dosage and frequency of dosage are as follows:

I hereby grant permission to any staff person to provide the following over-the-counter drugs to my son/daughter if requested

by my son/daughter (Check all that apply)

[ ] Tylenol [ ] Benadryl [ ] Advil [ ] Sudafed [ ] Midol [ ] Pepto Bismol [ ] Neosporin [ ] Kaopectate [ ] Immodium

[ ] Other __________________________

Add any dietary restrictions ____________________________________________________________________

_________________________________________________________________________________________

Photos and/or videos generated at camp may be used for later diocesan archival/promotional use.

Parent/Guardian Information: Home Phone Number: _____________________________________________

Work Number Father/Guardian: _____________________________________________

Cell Number Father/Guardian: _____________________________________________

Work Number Mother/Guardian: ____________________________________________

Cell Number Mother/Guardian: _____________________________________________

Non-parental emergency contact name : ________________________________________

Non-parental emergency contact phone number: __________________________________

Non-parental emergency contact 2nd phone number: _______________________________

I acknowledge that if any information changes I will notify the diocese/parish.

Date___________________Parent/Guardian Signature___________________________________________

updated 4/06

Diocese Of Boise Youth Permission & Medical Release Form Page 2