2009-2010 Medical Release Form

GRADE:

Last Name:

2009-2010 Medical Permission Slip This form is filled out at the beginning of the year and will be maintained in the church office in a secure file until July 30, 2010, when it will then be shredded. If any of your insurance information changes, please contact Steve for a new release.

I grant permission for the administration of first aid care by the person(s) in charge of Redeemer’s CYF ministry to (Name of student) ___________________________________________ and the transporting of my son/daughter/child under my guardianship to and from the ministry location to qualified physicians for treatment of illness or accidents. I understand that every effort will be made to promptly notify me in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In the event that I cannot be reached, I hereby give permission to the physician selected by the adult leadership to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery if deemed as necessary for my son/daughter/child under my guardianship. I also understand that there is no medical coverage for illness or injuries available through the church or any sponsoring leaders or group.

Parent/Guardian Signature ___________________________________ Date________________ -------------------------------------------------------------------------------------------------------------------Please Print Parent/Guardian Name _________________________________________________ Address______________________________________________________________________ _ Home Phone _____________________________ Other Emergency Numbers/people _________________________________________________ Insurance Company (in case of emergency) __________________________________________ Policy # ______________________________________________________________________ Doctor _____________________________________ Phone ____________________________ --------------------------------------------------------------------------------------------------------------------

Medical Information

GRADE: Last Name: It is important for us to know of any specific medical and physical information about your son/daughter/child under your guardianship to help insure their safety. Please complete the following: Name of Student ______________________________________________ A.

is allergic to the following foods: ____________________________________________ _______________________________________________________________________ _

B.

is allergic to the following medicines: _________________________________________ _______________________________________________________________________ _

C.

will be taking the following medications at the time of the trip: _____________________ _______________________________________________________________________ _

D.

other relevant information: _________________________________________________ _______________________________________________________________________ _

Parent/Guardian Signature ____________________________________ Date _______________