Medical Consent Form
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1Medical Consent Form
Participant Last Name:
First Name:
Home Phone:
Gender:
M
F
Birthdate:
Age:
Grade
Social Security No.
Parent/Guardian Name:
Cell Phone:
Work Phone:
Address:
City:
State:
Zip:
Alternate Adult Contact:
Relationship to participant:
Phone:
Emergency and Health Information
Does child have any of the following? (If yes, please explain.)
Allergies:
Yes
No
Heart condition:
Yes
No
Other:
Yes
No
Is child subject to:
Fainting:
Yes
No
Sleep walking:
Yes
No
Upset stomach:
Yes
No
Motion sickness:
Yes
No
Other:
Yes
No
Does child have a reaction to:
Bee sting:
Yes
No
Penicillin:
Yes
No
Other drugs:
Yes
No
Poison ivy, oak, sumac:
Yes
No
Other:
Yes
No
Please indicate anything else leaders should know to help avoid or deal with your child’s health.
Date of last tetanus shot:
Health Insurance
Insurance Co.
Policy No.:
Name of policy holder
Pre-certification required? _____yes _____no
If yes, phone number:
Doctor’s name _________________________________________
Phone
Medication Permissions
You have permission to give my child (check all that apply):
Robitussin cough medication
Pepto Bismol
topical cortisone (Cortaid)
acetaminophen (Tylenol)
Dramamine (motion sickness)
Solarcaine spray/lotion/ointment
diphenhydramine (Benadryl)
antacid (Rolaids, Mylanta)
topical antibiotic ointment
ibuprofen (Advil)
Emergency Procedure
In the event of any emergency leaders will attempt to first contact parent/guardian/doctor. If this is not possible, note below:
yes no
1. With my signature I hereby authorize First Aid by staff or youth workers.
yes no
2. With my signature I hereby authorize emergency medical care by hospital staff and or doctor selected by church
staff or youth workers.
yes no
3. With my signature I hereby authorize doctor selected by church staff or youth worker to hospitalize, secure treat-
ment for, and to order injection, anesthesia, blood transfusion or surgery.
If parent/guardian has answered “NO” to any of the above, parent/guardian must indicate procedure to be followed in the event that
parent/guardian is unable to be contacted.
Parent/Guardian Signature:
Date:
Print
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