Medical Authorization Release Form Page 2
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36. Medications
Date of Last Tetanus Shot: ____/____/____
Please list all daily medications:
Prescriptions
Dosages
________________________________________
__________________________________________
________________________________________
__________________________________________
________________________________________
__________________________________________
Non-Prescription Medicines
Dosages
________________________________________
__________________________________________
________________________________________
__________________________________________
________________________________________
__________________________________________
May your child be administered?
Pepto-Bismol
Yes
No
Cough Medicine
Yes
No
Aspirin
Yes
No
Tylenol
Yes
No
First Aid Cream/Spray
Yes
No
Emetrol
Yes
No
I, the undersigned parent/guardian, acknowledge and agree that the above medical information, which I
provided, shall be relied upon and used by the First Baptist Church, Hazlehurst, Georgia; its ministers;
personnel; chaperones; and sponsors in securing any needed medical attention or treatment for my above name
child. I, furthermore, agree to provide supplemental medical information in writing to the church should any
such additional information become available after the signing of this document. I also understand and
acknowledge that this form will be considered valid for a period of one year from the date of signature.
Signature of Consent: ________________________________________ Date: _________________________
(This form must be signed by a parent or legal guardian in the presence of a notary.)
******************************************************************************************
(To be completed by a Notary)
The foregoing instrument was acknowledged before me this ________ day of __________________, 20____
by ______________________________, who
_____ is personally known by me, or
_____ produced __________________________________ as identification and did take an oath.
(Affix seal below)
_________________________________________
Notary Public
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