NEWTOWN PRESBYTERIAN CHURCH

EMERGENCY MEDICAL FORM

Dear Parent/Guardian:

In the event that your son/daughter requires medical attention during one of the Youth Group sponsored trips, we request your authorization to act until you may be reached. Please read and complete the statement below. Your signature will provide the authorization that we need.

Name___________________________________________________Birth Date________________

Check one:  Youth___________  Adult Sponsor ___________

Home Address_____________________________________________________________________

____________________________________ Home Phone______________________

Father’s Name___________________________________ Work Phone ______________________

Other Emergency Contact _________________________________ Phone ____________________

Relationship_________________________________________________

Health Insurance_______________________________Policy No. ____________________________

______________________________ Policy No. ____________________________

Physician’s Name __________________________________________________________________

Address________________________________________________ Phone ____________________

Note any medical condition(s) we should be aware of:______________________________________

_________________________________________________________________________________

Allergies ________________________________Date of Last Tetanus Booster _________________

Present Medications________________________________________________________________

In the event that I cannot be reached and my son/daughter requires medical attention, I authorize a representative of the Newtown Presbyterian Church to act on my behalf.

Parent/Guardian Signature ___________________________________ Date__________________

Please initial the medications your child is permitted to receive.

Tylenol 1-2 tablets ___________ Benadryl 25mg_____________ Ibuprofen 200mg____________

Immodium 1-2 tablets_________ Sudafed 30mg______________ Dramamine 1-2 tablets_______