Lynchburg, Virginia

2010

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.

Child’s Name____________________________________________ Birth Date________________

Home Address_____________________________________________________________________

Email ___________________________________________

Home Phone______________________

Father’s Name___________________________________

Work Phone ______________________

Mother’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_______