Medical consent

Medical Consent Form
Parent/Guardian work phone___________________________ Emergency and Health Information
Does youth have . . . (if “yes” please explain)
_____yes _____no
Allergies? ___________________________________________________________ Heart condition? ______________________________________________________ Other? ______________________________________________________________ Is youth subject to . . . (if “yes” please explain)_____yes _____no Fainting? ___________________________________________________________ Sleep walking? _______________________________________________________ Upset stomach? ______________________________________________________ Motion sickness? _____________________________________________________ Other? ______________________________________________________________ Does youth have a reaction to . . . (if “yes” please explain)_____yes _____no Bee sting? ___________________________________________________________ Penicillin? __________________________________________________________ Other drugs? _________________________________________________________ Poison ivy, oak, sumac? ________________________________________________ Other? ______________________________________________________________ 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! If
this is not possible, note below:
___yes ___no
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.


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