Medical Consent Form
Parent/Guardian work phone___________________________
Emergency and Health Information
Does youth have . . . (if “yes” please explain)
Heart condition? ______________________________________________________
Is youth subject to . . . (if “yes” please explain)_____yes _____no
Sleep walking? _______________________________________________________
Upset stomach? ______________________________________________________
Motion sickness? _____________________________________________________
Does youth have a reaction to . . . (if “yes” please explain)_____yes _____no
Bee sting? ___________________________________________________________
Other drugs? _________________________________________________________
Poison ivy, oak, sumac? ________________________________________________
Please indicate anything
else leaders should know to help avoid or deal with your youth’s health.
Date of last tetanus shot _______________________Insurance Co. _______________________________________ Policy # __________________________Name of policy holder ____________________________________________________________________Pre-cert: _____yes _____no If yes, phone number _____/_____-_______Doctor’s name _________________________________________ Phone _____/_____-_______You have permission to give my youth:
___yes ___no robitussin (cough medication)
___yes ___no solarcaine spray/lotion/ointment
Emergency procedure: in the event of any emergency leaders will attempt to first contact parent/guardian/doctor!
this is not possible, note below:
1. With my signature I hereby authorize First Aid by staff or youth workers.
2. With my signature I hereby authorize emergency medical care by hospital staff and or doctor selected by church
3. With my signature I hereby authorize doctor selected by church staff or youth worker to hospitalize, secure
treatment 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.
Enhanced Fuzzy Single Layer Perceptron Kwangbaek Kim1, Sungshin Kim2, Younghoon Joo3, and Am-Sok Oh4 1 Dept. of Computer Engineering, Silla University, Korea 2 School of Electrical and Computer Engineering, Pusan National University, Korea 3 School of Electronic and Information Engineering, Kunsan National University, Korea 4 Dept. of Multimedia Engineering, Tongmyong Univ. of Information
A peer-reviewed electronic journal published by the Institute for Ethics and Emerging Technologies Cognitive Enhancement and Liberatory Possibilities of Antidepressant Therapy Journal of Evolution and Technology – Vol. 18 Issue 1 – May 2008 – pgs 124-128 Introduction A growing number of social critics have raised concerns about the widespread use of prescription antidep