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Name ____________________________________________________

MEDICAL INFORMATION

Family Physician:__________________________________ Phone:______________________________

Family Health Plan Carrier: _______________________________________________________

Policy/Contract Number: __________________________________________ Phone: ________________

Name of Policy Holder: __________________________________________________________

Optional:

My child is taking medication at present. My child will bring all such medications necessary, and such medications

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

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

__________________________________________________________________________________________

______________________________________________________________________________

Signature:_____________________________________ Date:__________________________

Optional Instruction:

Do not give non-prescription medication of any kind to my child without my express permission.

Exceptions: _______________________________________________________________________________

Signature:_________________________________Date:_______________________

Allergic Reactions (medications, foods, plants, insects, etc.) ____________________________

_____________________________________________________________________________

Date of last tetanus:___________________________

Special Dietary Considerations:___________________________________________________

_____________________________________________________________________________

Physical Limitations:____________________________________________________________

You should be aware of these special medical or psychological conditions of my child:

_____________________________________________________________________________

CODE OF CONDUCT

I hold that my child will conduct himself/herself in a proper manner and failure to abide by standard codes of

conduct will cause my child to be dismissed from the above named event. I understand that if my child is

dismissed from the event I will be expected to travel (or send an adult designee) at my expense to the event

location and retrieve my child.

Signature:_____________________________________ Date:__________________________

Form CH-1

02/2001

Form Ch-1 - Parental/guardian Consent Form And Liability Waiver - Diocese Of Birmingham Page 2