Awesomesayfers.org

Young Friend’s Name _____________________________
There may be times when your child suffers from mild symptoms that can be treated with simple over-the-counter medications that we have available in our first aid kit.
If you give permission for your child to receive the following medications, check the yes column.
If that column is not checked, then permission is
not given.
Time and Date Given
(For use by retreat FAP)
reactions: only in severe emergencies, and Information on Tetanus Shots
Date last shot: Don’t know______ Less than 5 years_____ 5 -10 years:_____ Over 10 years ________ Is your child is allergic to tetanus:_____ yes _____ no ________ If there is an accident for which a tetanus shot is recommended, may we authorize it? Yes_____ Does your child have asthma? Yes____ No____ If yes, please answer the following questions:Does your child use a daily medication? If yes, please list the medication(s) and the dosage(s): _______________________________________________________________________________________________ How often does he/she experience an asthma attack? ________________________________________ Has your child ever been hospitalized because of asthma? ____________________________________ Is your child able to recognize and treat the onset of an attack?_________________________________ Can your child recognize when the attack is severe and requires the attention of medical professionals? ___________________________________________________________________________________ How should we respond to a breathing problem with your child? _______________________________________________________________________________________________ SOUTHERN APPALACHIAN YOUNG FRIENDS (SAYF) Young Friend: ___________________________________________________Date of Birth_________________ Parent or Legal Guardian: _____________________________________________________________________ Address:____________________________________________________________________________________________________________________________________________________________________________________ Phone #s during the retreat (home. Work, cell, pager):____________________________________________ Emergency phone number (and name) if parent cannot be reached: _______________________________ I give permission for my minor child to attend Southern Appalachian Young Friends Retreats. In theevent of an emergency, I authorize the adult leaders of SAYF to act for me to make any and alldecisions for me concerning the medical treatment or hospitalization of my minor child; to consent toany X-Ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advisedand supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the lawsof the state where the services are rendered, either at a doctor's office or in a hospital. I specificallyrequest that an adult leader accompany my child during any evaluation and treatment to the sameextent as I would as a parent and guardian unless my child requests otherwise for reason of privacy. Iexpect to be contacted as soon as possible. I absolve the adult leaders from personal liability arisingfrom the exercise of such authority, including any and all costs, expenses, and charges for medical orhospital care provided by or received from whomsoever, and costs of transportation related thereto. Iaffirm that the following insurance and medical information is complete and correct.
Signature of Parent or Legal Guardian:____________________________________ Date_________________ Insurancecompany:_____________________________________________________________________________________ Address: ________________________________________________________________________________ Phone number_______________ Policy number_____________ Policyholder:_____________________ Family doctor (and phone number):_____________________________________________________________ Prescriptions currently taken (please keep usup-to-date!):__________________________________________________________________________________ ______________________________________________________________________________________________ Current medical or psychological conditions, allergies, etc ________________________________________ ______________________________________________________________________________________________ Other information that adult leaders and/or emergency room physician should know: _______________ ______________________________________________________________________________________________ PLEASE DONT FORGET TO FILL OUT PAGE 2 OF THIS FORM!

Source: http://www.awesomesayfers.org/_forms/Med_release-2012.pdf