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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

Attention parents and guardians:

Attention Parents and Guardians: Please complete and sign this form. Teachers must return these forms to the Sherman Lake YMCA prior to the group’s arrival at camp. ALL INFORMATION IS KEPT CONFIDENTIAL. Sherman Lake YMCA Outdoor Center To download the Integrated Education overnight information packet please go to the website 1)click on school programs 2)click on progra

Curriculum vitae

Daniil Petrenyov Institute of Radiobiology NAS Belarus Fedyuninskogo Str. 4, Gomel 246007,BELARUS HOME ADDRESS: Makayonka St. 29-30, Gomel, 246038, BELARUS PERMANENT Mayakovskogo St. 12-10, Minsk, 220006, BELARUS MAILING ADRESS: +375 (296) 540 489 Daniil.Petrenyov gmail.com EDUCATION and EMPLOYMENT HISTORY: 2004- Present Researcher , Endocrinology and Biochemistry lab., Ins

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