MEDICAL PERMISSION FORM
Diocese Parish School ________________
Participants Name _________________________________________________________________
Destination ______________________________________________________________________
TO WHOM IT MAY CONCERN:
I/We understand that first aid will be available on the above trip. I/We further understand that should an accident, injury, or illness occur, medical and/or hospital care will be obtained.
I/We realize that the sponsors will make a reasonable effort to notify me/us in case of accident, injury, or illness: however, should they be unable to contact me/us, they have my permission to pursue a course of medical action which is in the best interest of the child.
I/We grant permission to the administration of first aid care to (name) by the people in charge of the and those transporting my child to and from s their judgment deems advisable and to make the necessary referrals to qualified physicians or health care providers for treatment of illness or accidents. I/We understand that a reasonable 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 case of medical emergency, in the event I/we cannot be reached, I/we hereby give permission to the physician or health care provider selected by the adult staff to hospitalize, secure proper treatment for , and order whatever injection, anesthesia, or surgery said physician or health care provider deems necessary for the child.
A doctor, clinic, hospital, or health care provider may proceed with a medical or surgical treatment that such sponsor may authorize.
I further understand that I will be responsible for all medical, surgical, and transportation costs which may be incurred.
INSURANCE INFORMATION:
Insurance Company Policy No. _____________________________
_______________________________________ __________________________________________
(Father) (Home & Work Telephone #)
_______________________________________ __________________________________________
(Mother) (Home & Work Telephone #)
If unable to contact either parent above, I/we grant permission to contact:
_______________________________________ ___________________________________________
(Friend or Relative) (Home & Work Telephone #)
________________________________________ ___________________________________________
(Family Physician) #9; (Physician’s Telephone #)
______________________________ ________ _____________________________ ________
Parent/Legal Guardian Signature Date Parent/Legal Guardian Signature Date
If there are any medical restrictions/problems - please note them on the back of this sheet.
MEDICAL PERMISSION FORM
Diocese Parish School _______________________
Participants Name: ___________________________________________________________________
Destination _________________________________________________________________________
TO WHOM IT MAY CONCERN:
I/We understand that first aid will be available on the above trip. I/We further understand that should an accident, injury, or illness occur, medical and/or hospital care will be obtained.
I/We realize that the sponsors will make a reasonable effort to notify me/us in case of accident, injury, or illness: however, should they be unable to contact me/us, they have my permission to pursue a course of medical action which is in the best interest of the child.
I/We grant permission to the administration of first aid care to (name) by the people in charge of the and those transporting my child to and from as their judgment deems advisable and to make the necessary referrals to qualified physicians or health care providers for treatment of illness or accidents. I/We understand that a reasonable 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 case of medical emergency, in the event I/we cannot be reached, I/we hereby give permission to the physician or health care provider selected by the adult staff to hospitalize, secure proper treatment for , and order whatever injection, anesthesia, or surgery said physician or health care provider deems necessary for the child.
A doctor , clinic, hospital, or health care provider may proceed with a medical or surgical treatment that such sponsor may authorize.
I further understand that I will be responsible for all medical, surgical, and transportation costs which may be incurred.
INSURANCE INFORMATION:
Insurance Company Policy No. _______________________
______________________________________ __________________________________________
(Father) (Home & Work Telephone #)
______________________________________ __________________________________________
(Mother) #9; (Home & Work Telephone #)
If unable to contact either parent above, I/we grant permission to contact:
_______________________________________ __________________________________________
(Friend or Relative) #9; (Home & Work Telephone #)
_______________________________________ __________________________________________
(Family Physician) (Physician’s Telephone #)
__________________________ ________ ______________________________ ________
Parent/Legal Guardian Signature Date Parent/Legal Guardian Signature Date
REQUEST TO ADMINISTER MEDICATION
NOTICE TO PARENT(S)/GUARDIANS
Whenever medication is to be taken at camp, this form must be completed and signed. (This includes prescription and non-prescription medications). Prescription medication must come to camp in the original container from the pharmacy. This shows the child’ name, the physician or dentist’s name, the prescription number, name of medication and dosage. Non-prescription medications must also come to camp in its original container. Thank you for your cooperation.
Name of participant
Physician or Dentist Name
Prescription drugs to be taken:
Medication Prescription Number ________________
Time to be given Dosage ___________________________
Medication Prescription Number ________________
Time to be given Dosage ___________________________
Medication Prescription Number ________________
Time to be given Dosage ___________________________
Non-prescription drugs to be taken:
Drug Time to be taken Dosage ____________
Drug Time to be taken Dosage _____________
Drug Time to be taken Dosage _____________
The medication should be administered on the following basis (check one):
( )Until medication is completely used as per above dosage ( )Until ___________________________
REASON FOR MEDICATION (s)
I hereby request that Take the above medication(s) at camp as noted and that the nurse or his or her designee administer the medication. I understand it is my responsibility to furnish this medication and proper instructions for administering the same. I further understand that any adult camp leader who administers this medication to my child shall not be liable for damages as a result of the administering of the medication in accordance with this request and I shall indemnify and hold blameless camp leaders against any claim for such damages.
______________________________________________
Signature of Parent or Guardian Date