Parental/guardian Permission Form And Release - Travel Form And Medical Matters (Page 2 of 2) in pdf

DIOCESE OF ALLENTOWN

PARENTAL/GUIDARIAN PERMISSION FORM & RELEASE

MEDICAL MATTERS

I (we) hereby warrant that to the best of my (our) knowledge, my (our) child is in good health,

and I (we) assume all responsibility for the health of my child.

Emergency Medical Treatment: In the event of an emergency, I (we) hereby give permission to

transport my (our) child to a hospital for emergency medical or surgical treatment. I (we) wish

to be advised prior to any further treatment by the hospital or doctor. In the event of an

emergency, if you are unable to reach me (us) at the above numbers, contact:

Name & relationship:__________________________________Phone:____________________

Family doctor:________________________________________Phone:____________________

Medical Insurance Information:

Health Plan Carrier:_____________________________________________________________

Group #:______________________________________________________________________

I.D. #:________________________________________________________________________

Medications: My (our) child is taking medication at present. My (our) child will bring all such

necessary medications, 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: ________________________________________________

______________________________________________________________________________

I (we) hereby grant permission for non-prescription medication (such as aspirin, throat lozenges,

cough syrup) to be given to my (our) child, if deemed appropriate.

Specific Medical Information: The parish/school should be aware of the following medical

conditions. (The parish/school will take reasonable care to see that the following information

will be held in confidence.)

Allergic reactions (medications, foods, plants, insects, etc.): _____________________________

Immunizations: (Date of last tetanus/diphtheria immunization: ___________________________

Does child have a medically prescribed diet? _________________________________________

Any physical limitations? ________________________________________________________

Has child recently been exposed to contagious disease or conditions, such as mumps, measles,

chicken pox, etc.? If so, date and disease or condition: _________________________________

Other medical conditions of my (our) child: __________________________________________

______________________________________________________________________________

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