Upstate New York 2012
NEWTOWNPRESBYTERIANCHURCH- 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_______