2008-09 Medical Information and Permission for Treatment Form by coreymcintyre


									                                         2008-09 Medical Information and
                                          Permission for Treatment Form
                                                         Our Savior's Lutheran Church

         Please complete this form and we will keep it on file for all events, including all trips. You will need to sign
permission forms for “out-of-building” events, but won’t have to list your medical and phone information each time. If
your insurance information or contact numbers change during the year, just note that in the appropriate spot on the
permission slip for individual events. The emergency contact person should be someone other than a parent, who can be
contacted if we are unable reach you. (i.e. grandparent, aunt/uncle, or neighbor) If you are not a member of Our Savior’s
please include your address on the back of this form.
         If medical attention is needed, the process flows better when we have a copy of your insurance card. Please copy
both sides of your insurance card on the reverse side of this sheet. (The office is more than willing to help you do this) For trips,
we will need up to date Permission forms. Please let us know about changes prior to our leaving for any trip!
         Parents are responsible for medical insurance coverage for your child while he/she is attending any organized
activity. We love your child and will guard them as best we can. By signing this form, you are indicating your partnership
with us. Please note that your child will not be permitted to participate in events outside the church without this signed form
and a copy of your insurance card. Thank you for your cooperation and partnership!

Youth’s Name: _________________________________________________                                     Grade: ____________

                                                     Contact Information

Mother’s Name: ______________________________________ Home Phone: ___________________

Work Phone: _________________________________                           Cell: __________________________________

Father’s Name: ______________________________________ Home Phone: ___________________

Work Phone: _________________________________                           Cell: __________________________________

Emergency Contact: ____________________________________ Home Phone: _________________

Work Phone: _________________________________                           Cell: __________________________________

Family Physician: _____________________________________                               Phone: _______________________

Are all Immunizations current?             Yes / No              Date of Last Tetanus shot: _________________

Medical Conditions - Please list any medical, diet, or personal information (e.g. allergies to medications or foods,
medical conditions, medications, family situations, etc.) from which our adult leaders would benefit when they
are responsible for your child.

I give permission for medical treatment deemed necessary by qualified medical personnel while my child is under
   the care of Our Savior’s Lutheran Church and its representatives. The purpose of this information form is to
  allow my child to receive immediate medical attention in my absence. I will be contacted as soon as possible
                                     should medical treatment be required.

Parent Signature: _________________________________________________________ Date: ________________

To top