2011 medical form

Revised 2/21/2011
SoCal Girls Ministries Teen Girl Retreat Medical Form
(All Girls and Leaders Must Complete and Return with Registration Form)
Student/Leader Name: ___________________________________ Age: ____________ Parent/Guardian: _________________________________________________________ Home phone: (__ ___) ____________________________________________________ Work phone: (____ _) ____________________________________________________ Cell phone: (______) ____________________________________________________ Church Name and City: ___________________________ Phone: ( ) ____________ Physician’s name: _______________________________ Phone: ( ) ___________
Insurance Company’s Name: _______________________________________________
Insurance Company’s Policy/Medical Number: _________________________________
Insurance Company’s Mailing Address and/or Phone Number: _____________________
________________________________________________________________________
*Note: All insurance information must be listed on this form.
Ongoing medical condition(s):
The camper has or has had (Please check yes or no for all): Eye, Ear, Nose, Throat Trouble Yes No Migraines Epilepsy or Other Nervous System Disorder Yes No Any diet restrictions? Yes No If yes, please specify: _____________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Other conditions or considerations that we should know while at camp: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Name: __________________________________________________________________
Medications taken regularly

Medications taken only when needed (i.e., medication for migraine or allergies)
Rescue inhalers will be checked in with the nurse. After check in, the inhalers will be given to the adult responsible for the minor. Over the counter medications are available and will be dispensed only if you give permission. Do you give permission for your child to receive the following? (Please check yes or no for all) For fever, minor pain or cramps: (*note this medication does contain aspirin) Benadryl/Diphenhydramine Yes No Calamine Lotion
In case of emergency: I hereby give permission to the Girls Ministries Director to select
transportation to the District’s chosen physician who may hospitalize, secure proper treatment for,
and order injections, anesthesia, or surgery for my child or for me (if over 18 years of age) as
named above. Signature authorizes Health Supervisor to administer medications.

Signature _________________________ Relationship to Student __________________ Date ________
Signature of Parent/Legal Guardian of girl under age of 18
Signature of Leader or Staff (18 years or older)

Source: http://socalnetwork.org/files/events/2011_Medical_Form.pdf