Medical consent form

THIS FORM MUST BE COMPLETED FRONT AND BACK AND NOTARIZED
Medical Consent Form
Last name__________________________________ First name_______________________________ Home phone number_________________________ Male____ Female____ Birth date___________ Age Grade(just completed)____________________ Social Security Number____________________ Parent(s)/Guardian(s) name(s)_______________________________________________________________ Parent(s)/Guardian(s) address(es)_____________________________________________________________ Parent(s) work phone number(s)______________________________________________________________ Parent(s) pager or mobile phone number(s)______________________________________________________ Emergency Contact (Other than parent/guardian- name /relationship/phone numbers)_____________________ _________________________________________________________________________________________ +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Emergency & Health Information
Does youth have…(if “yes” please explain) ____yes ____no Food allergies?___________________________________________________________ Environmental allergies?___________________________________________________ Heart Condition?_________________________________________________________ Other?__________________________________________________________________ Is youth subject to…(if “yes” please explain) ____yes ____no Fainting?________________________________________________________________ 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 which teachers/leaders should know to avoid or help deal with your youth’s health____________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Date of last tetanus shot:___________________________________ You have my permission to give my youth:
____yes ____no Robitussin (cough medicine)
____yes ____no Dramamine (for motion sickness) ____yes ____no Rolaids, Mylanta (antacid) ____yes ____no diphenhydramine (Benadryl) ____yes ____no ibuprofen (Advil, Motrin) ____yes ____no topical antibiotic ointment (polysporin) ____yes ____no topical cortisone ointment (Cortaid) ____yes ____no Solarcaine spray/lotion/ointment
EMERCENCY PROCEDURE: IN THE EVENT OF ANY EMERGENCY, LEADERS/TEACHERS WILL FIRST
ATTEMPT TO FIRST CONTACT PARENT/GUARDIAN/DOCTOR! In case this is impossible, note below:

____yes ____no
1. With my signature, I herby authorize First Aid by staff or youth workers. 2. With my Signature, I herby authorize emergency medical care by hospital staff and/or doctor selected by church staff or youth workers. ____yes ____no 3. With my signature, I herby authorize doctor(s) selected by the church staff or youth workers to hospitalize, secure treatment for, and to order injection, anesthesia, blood transfusions, or surgery. If parent/guardian has answered “NO” to any of the above, parent/guardian must indicate procedure to be followed in the event leaders/teachers are unable to contact parent/guardian/designee_____________________ _________________________________________________________________________________________ _________________________________________________________________________________________ +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Insurance Information
My youth has health insurance _______yes _______no. If yes complete the form below. Insurance Company_________________________________________________________________________ Policy/Certificate number_____________________________________________________________________ Name of Policy Holer________________________________________________________________________ Pre-certification required? ______yes _____no If yes, phone number__________________________________ Doctor’s name and phone number______________________________________ ( )________-___________ Parent/Guardian Signature___________________________________________ Date____________________ Notary’s signature_________________________________________________

Source: http://fairlawnlutheran.org/Images/2011vbsmedconstent.pdf