Microsoft word - lym camper med release form 2013.doc

Name: _______________________________________________________________________
Last First Middle
Birth date: _______________________ Male: ____ Female: ____
Parents: _____________________________________________________________________
Address: _____________________________________________________________________
Home Phone: ___________________________ Work Phone: __________________________
Cellular: ________________________________
General - Is Youth subject to: (If "yes" - explain)
_____ Yes _____ No Fainting
_____ Yes _____ No Sleep Walking
_____ Yes _____ No Upset Stomach
_____ Yes _____ No Other
Reactions / Allergies - Is Youth subject to: (If "yes" -explain and list medication)
_____ Yes _____ No Penicillin
_____ Yes _____ No Other drugs
_____ Yes _____ No Bee sting
_____ Yes _____ No Poison Ivy, etc.
_____ Yes _____ No Other allergies
_____ Yes _____ No ___________
_____ Yes _____ No ___________
Medications / Conditions -Is Youth subject to: (If "yes" - explain and list medication)
_____ Yes _____ No Asthma
_____ Yes _____ No Bronchitis
_____ Yes _____ No Diabetes
_____ Yes _____ No Heart condition
_____ Yes _____ No Sight / Hearing
_____ Yes _____ No Wears Contacts
_____ Yes _____ No Serious Illness or injury in last ten years
Date of Last Tetanus Shot: _________________________
Please indicate ANYTHING else that adult leaders should know to help deal with any medical
situation that may arise:__________________________________________________________
EMERGENCY INFORMATION (please include photocopy of insurance card)
Health Insurance Co. _____________________________________ Policy #_______________
Family Doctor ___________________________________________Phone _________________
Other #'s______________________________________________________________________
Other Contact Person__________________ __________________ Relationship ____________
Home Phone: ___________________________Work Phone: ____________________________
Cellular: ________________________________
Page 1 of 2
I, the undersigned parent and/or legal guardian of_________________________,a minor under age 18, do hereby authorize the camp nurse, Robert Milkert or an authorized adult member of Lutheran Youth Ministries to consent to: 1. Medical, surgical and dental care for such minor child; 2. Consent to any diagnostic tests, medical, surgical or dental procedure or treatment as may be considered necessary by the physician, surgeon, dentist, or other health care personnel providing care for such minor child: 3. and on my behalf to: a. employ physicians, surgeons, dentists, nurses and other health care personnel as may be deemed necessary for such minor child, b. admit such minor child to any hospital, clinic, emergency room, laboratory, or other health care or diagnostic facility for examination, treatment, surgery or care, c. sign all necessary consents and authorizations 4. any non-emergency first aid, including the administration of: ____ _ Yes _____ No Acetaminophen (Tylenol or similar pain reliever) _____ Yes _____ No Pepto Bismol / Imodium AD _____ Yes _____ No Antacid (Tums, Maalox) _____ Yes _____ No Decongestant (Sudafed) _____ Yes _____ No Benadryl It is understood that this authorization is given in advance of the occurrence of any condition or situation that would necessitate any such medical, surgical or dental care being required, but is given to provide authority to obtain such care if it should be required. This document shall be in effect for the dates of July 14, 2013 through June 30, 2014. IN WITNESS WHEREOF, I have executed this Authorization to consent to Medical and Dental Care this _______ day of _________, 2013 ___________________________________ Parent / Legal guardian ___________________________________ Parent / Legal guardian State of _______________ ________________ County On this day of ,2013, before me, a Notary Public, personally appeared and known to be the person who executed the above Consent and stated that it was executed as their free act and deed. ___________________________________ (SEAL) Notary Public Page 2 of 2


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