Health record and consent for treatment

Health Record and Consent for Treatment – School Year 2013-2014
Note: Parent/Guardian - It is important that you complete the following Health Record.
Your son/daughter must turn this form in with the registration.
NAME OF STUDENT:______________________________________________________________________ ADDRESS________________________________________________________________________________ _________________________________________________________________________________ Name of Medical/Health Insurance Company_____________________________________________________ Policy #___________________________ Phone Number for Insurance Verification (from Insurance card) _____________________________________ 1. Does the student have any known physical defect or illness, which might interfere with his/her participation in strenuous activity? If so please explain. 2. Does the student have any severe allergies or reactions to drugs or medicines? Explain. 3. Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.). 4. Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)_____________________________________ 5. Is your son/daughter living with  both parents 6. Past Medical History: Insect Stings/bites:___________________________________________________ Poison Sumac/Oak/Ivy:_________________________________________________ Previous Operations or serious illness: 7. Has your child had any of the following childhood diseases:
NOTICE: The following non-prescription medications will be available for your child if necessary. Your
permission is needed before any medicine can be administered. Any medication you DO NOT wish your child to
have should be circled:
Robitussin (cough & congestion)
EXPECTING THAT THE LEADERS FOR THE TRIP WILL EXERCISE REASONABLE CARE IN OVERSEEING THE ACTIVITIES OF THE STUDENTS, I REQUEST AND AUTHORIZE THE LEADERS TO SEEK WHATEVER MEDICAL CARE IS NECESSARY AND ADVISABLE SHOULD AN EMERGENCY ARISE WHICH WOULD REQUIRE TREATMENT FOR MY SON/DAUGHTER. _______________________________________________ Signature of the Parent/Guardian Telephone: (_____)-_____-_________ (_____)-_____-___________ Should the parent or guardian (primary contact) not be available, who should we contact (secondary contact) in case of emergency? _________________________________________________ Name Telephone: (_____)-_____-_________ (_____)-_____-___________ I, the undersigned parent/guardian, do hereby grant permission for my son/daughter, named above, to attend Lawndale Baptist Church’s Student Ministry Events this school year 2013-2014 for which he/she has signed up and paid for. In order that my son/daughter may receive the proper medical treatment in the event that he/she may sustain injury or illness during the period of the above trip, I hereby authorize the leaders to obtain or provide medical treatment for my son/daughter for such injury or illness during the trip, and I hereby hold Lawndale Baptist Church and the leaders, harmless in the exercise of this authority. I further understand that there is always a possibility that my son/daughter may sustain physical illness or injury while on this trip. If this occurs, I hereby authorize Lawndale Baptist Church and the leaders to refer my son/daughter for medical treatment, including a medical treatment center (hospital, etc.) I further acknowledge and understand that I will be responsible for any medical bills that may be incurred on behalf of my son/daughter for physical illness or injury that he/she may sustain during the event / trip. Understanding that there is always a possibility that my son/daughter may sustain physical illness or injury, I acknowledge and understand that my son/daughter is assuming the risk of such physical illness or injury by his/her participation, and I further release and hold harmless the Lawndale Baptist Church and the leaders from liability for any and all claims for personal illness or injury that my son/daughter may sustain during the mission trip. I further acknowledge and understand that my son/daughter will be responsible for his/her failure to abide by the rules and regulations of the event / trip named above. Signed______________________________________ (Sign only in the presence of a notary)

Relationship to Student _______________________________________________________
North Carolina _______________County I, _____________________________, a Notary Public for _____________ County, North Carolina, do hereby certify that ________________________________ and ________________________ personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal, this the ______ day of ______________, 20 ____. ________________________________________________ My commission expires _______________________, 20 ____.

Source: http://www.lawndalebaptist.org/ministries/students/2013-2014_MedForm.pdf