Authorization for medical treatment

White’s Chapel United Methodist Church 2011-2012 ________________________________________________________________ ________________________ Child’s Name ________________________________________________________________ ________________________ Physician’s Name and Address In the event that I cannot be reached to make arrangements for medical treatment, I authorize any representative of White’s Chapel United Methodist Church (WCUMC) to administer first aid and/or to call EMS for evaluation and possible transport of __________________________ (my child) to the nearest hospital. I authorize and hereby give my consent for any necessary medical treatment, emergency or otherwise, furnished by any licensed physician, hospital, or emergency treatment clinic (health care provider), and I agree to pay all medical fees incurred in connection with the treatment of my child under the authority granted herein. I hereby release WCUMC and any health care provider, and any of their respective agents, employees, officers, or representatives, from any and all liability for any action taken on behalf of my child pursuant to the terms of this medical authorization. In addition, I hereby give permission for my child to participate in any activities which constitute a part of WCUMC Childcare Program. I hereby release White’s Chapel United Methodist Church, its agents, employees, officers, or representatives, from any and all liability which might arise out of my child’s participation. __________________________________________________________________ _______________________ Signature of parent or legal guardian Please note that for the safety of our children and Caregivers that parents are asked to keep their children at home if they have been sick within the last 24 hours. If your child has been treated with antibiotics, he/she should be on the drug for at least 24 hours before coming to the church. Thank you for your cooperation! Please list any special problems, needs, or disabilities your child has: _________________________________________________________________________________________ _________________________________________________________________________________________ List over the counter and prescription medications your child is currently taking and include dosages: _________________________________________________________________________________________ _________________________________________________________________________________________ Did you bring any emergency medications for your child (such as an epi pen or inhaler)?______________ Please explain:___________________________________________________________________________ ________________________________________________________________________________________ Does our Medical volunteer have your permission to administer your emergency medication if needed?____ Does your child have: Other:______________________________________________________ Does your child have allergies/allergic reactions to: _____ Medicine (specify) :___________________________ ________________________________ _____ Insect Bite(specify):___________________________ ________________________________ _____ Food (specify):_______________________________ ________________________________
Does our Medical volunteer have your permission to administer Benadryl to your child in case of an allergic
reaction? _________________
Please note that Rold Gold pretzels, Ritz Crackers, Popcorn, Cheese pizza, fruit, and Lemonade can be provided for
snacks. Does your child have a problem with these snacks? ______________________
All of my child’s immunizations are up to date: Yes or No If no, please explain:_____________________________
List any previous serious illnesses or injuries:
List any hospitalization during the past 12 months and reason for it:
Insurance Company _________________________________________ Group #___________________________
Phone #__________________________________ Member ID #___________________________________________
Emergency Contact Information:
Parent name: _________________________________________ Cell phone #___________________________
Parent name: _________________________________________ Cell phone #___________________________
Note that the security tag you receive upon check-in is needed to pick up your child. If someone else is allowed to
pick up your child, please list their name:______________________________________________________
Please call Dorothea Christ on her cell phone at (817)800-6477 with any questions.


Microsoft word - 120314 pharmac submission

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