Parental/guardian Medical Information And Consent Form printable pdf download

Diocese of Orlando Parental/Guardian Medical Information & Consent Form

Participant’s Name:______________________________________ Date of Birth:________________________

Address__________________________________________ City/State/Zip________________________________

Home Phone:____________________

Father’s Name: ________________________________________

Phone: ________________________________

Mother’s Name: _______________________________________

Phone: ________________________________

Emergency Contact Name: _____________________________ Phone: ________________________________

Language Spoken by Emergency Contact: ______________________________________

Medical Matters

I hereby warrant to the best of my knowledge, all the information provided is true and correct and I assume all responsibility for

the health of my child. I understand it is my responsibility to update the Medical Information & Consent Form if there are any

changes to my child’s health. (Please initial) _______

Emergency Medical Treatment

In the event of an emergency, I hereby give permission to transport my child to a hospital/clinic for emergency medical or

surgical treatment. (Please initial) _______

Family Doctor _________________________________________

Phone _____________________________

Medications

I hereby Grant Permission for my child to be given the following provided medications. All medications must be well labeled.

: Any/all prescription medications must be in original pharmacy container with young person’s name on the prescription

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label. Non-prescription/over-the-counter medications must be in original container with young person’s name on the container.]

I release and hold harmless (entity name) ____________________, the Diocese of Orlando and any other religious, employees,

volunteers, agents and representatives from any injury or harm resulting from administering the medication.

(Please initial) _______

Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency, are as follows:

Medication: ___________________Dosage: _______________ Administer: _______________________________________

Medical Conditions Information:

(Reasonable steps will be taken to keep this information confidential, but it will be

shared with Diocesan personnel and others, as warranted.)

My son/daughter:



Is allergic to the following medications ___________________________________________________________________



Has had an episode of the following or has been diagnosed with: ” Seizures ” Asthma ” Diabetic



Has had allergic reactions to the following (foods, dyes, latex, etc.)_____________________________________________



Has had a medical surgery within the last six months? ” Yes ” No

Still under doctor’s care? ” Yes ” No



Has a medically prescribed diet (please explain) ____________________________________________________________



Has the following physical limitations____________________________________________________________________



Immunizations current and up to date? ” Yes ” No

Date of last tetanus/diphtheria immunization________________



You should also be aware of these special medical conditions of my child: ________________________________________

Insurance Information

No, I do not carry medical insurance at this time.

 I do carry medical insurance at this time.

Insurance Carrier: ______________________________________

Name of Insured: _____________________________

Insurance Policy Number: ______________________________________________________________________________

In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the participant’s parent/guardian.

I fully understand the foregoing statements and sign this Medical Information & Consent Form knowingly, freely, and willingly.

____________________________________________________

______________________

Parent/Guardian Signature

Date

4/2013

(must sign for any participant under 18 &/or 18 or older & in high school)

Parental/guardian Medical Information And Consent Form

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