Microsoft word - youth permission form.doc

Rockville Presbyterian Church Youth Group
Youth Emergency Contact and Medical Information Sheet
2011-2012
Student Information:
Full Name: _______________________________________ Birthday: _____-_____-______ Grade: ______
Address:________________________________________________________________________________
Parent/Guardian Phone Number(s):
(H) ________________ Mobile: ___________________ Text? ___Yes ___ NO (W) _________________
(H) ________________ Mobile: ___________________ Text? ___Yes ___ NO (W) _________________
Parent/Guardian Email(s):
________________________________________________________________________________________
Non-Parent Emergency Contact Information
Name: ___________________________________ Relationship: __________________________________
Address: _______________________________________________________________________________ Phone Numbers: _________________________________________________________________________
Insurance Information
Name of Policy Holder:
_______________________________________________________________ _______________________________________________________________ Group #: __________________________________ Policy #: _______________________________ Name of Doctor: ____________________________ Phone Number: __________________________
Health History Information
Pre-existing or present medical conditions:____________________________________________________
Name and dosage of any medications that must be taken:_________________________________________
_______________________________________________________________________________________
Allergies:_______________________________________________________________________________ Date of Last Tetanus Shot:_____________________ Does Student Wear Contact Lenses? ____________ Any Activity Restrictions? _________________________________________________________________ Permission To Administer Medications
I give my permission for the below circled indicated medications to be administered to my youth at my youth’s
request or as deemed necessary by adult leaders. (Circle all that apply)
Ibuprofen
Rockville Presbyterian Church
Youth Permission Form and Medical Waiver for Youth Group Activities
2011-2012
As a parent/guardian of (youth’s name) ______________________________________ (hereafter “my youth”), I give my permission for my youth to participate in all Rockville Presbyterian Church youth group activities and events from September 1, 2011 through August 30, 2012. I understand that youth may not drive any other youth on any RPC events. I give my permission for my youth to ride with an unaccompanied RPC leader, should the situation arise, during any off-site RPC event or activity. I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the person listed on the opposite side of this form. In the event that he/she cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, secure medical treatment, and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. If I do not have medical insurance, I understand that I am responsible for the costs that are incurred. I understand all reasonable safety precautions will be taken while the youth are in authorized locations during the events and activities of the RPC youth programs. I understand the risk of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Rockville Presbyterian Church, its leaders, employees, and volunteer staff liable for damages, losses, or injuries incurred by my youth. ___________________________________ ___________________________________ Parent/Guardian Name (Printed)

Source: http://www.rockvillepres.org/wp-content/uploads/2012/03/YouthPermissionForm.pdf