MEDICAL INFORMATION/RELEASE
Child/youth full name: ____________________________________________
Birth date: ____/______/_____
Allergies: _____________________________________________________________________
(foods, medications, insect bites, etc.)
Prescriptions/reason: (e.g. Claritan/allergies; Ritalin/ADD). All prescription meds will be administered by an adult counselor.*
______________________________________________________________________________________
____ Over-the-counter medicines (e.g., Tylenol, Pepto-Bismol) may be administered to my C/Y for minor ailments.
Other health issues concerning my C/Y are: ____________________________________________________________
______________________________________________________________________________
C/Y’s Primary Physician: __________________________ Telephone No: _________________
Dental Insurance Carrier: ______________________ Policy No.:____________________
Other Important Health Care Professionals (e.g., eye doctor, orthodontist, psychotherapist, allergist, etc):
Emergency Contact/Relationship/Phone Numbers (please list at least one person not in your household: e.g. Joan Smith/neighbor/123-4567) ______________________________________________________________________________
IN CASE OF EMERGENCY, I HEREBY AUTHORIZE THE ADULT LEADER IN CHARGE TO SELECT AND SECURE APPROPIATE MEDICAL PERSONNEL FOR MY CHILD/YOUTH (C/Y). FURTHER, I AUTHORIZE THOSE MEDICAL PERSONNEL TO PERFORM AND PROVIDE ALL REASONABLY NECESSARY MEDICAL CARE INCLUDING, BUT NOT LIMITED TO, DIAGNOSTICS (E.G., RADIOLOGY); HOSPITALIZATION, ANESTHESIA, SURGERY AND PRESCRIPTION DRUGS, ADVISABLE FOR THE HEALTH OF MY CHILD/YOUTH.
______________________________________ ___________________________________
(Parent or Legal Guardian’s Signature) (Date)
*It is understood that certain health issues such as asthma or diabetes necessitate that a c/y be able to participate in his/her own
disease management. If so, please attach an explanatory rider to this document.