GRADE: Last Name:

2009-2010 Medical Permission Slip

This form is filled out at the beginning of the year and will be maintained in the
church office in a secure file until July 30, 2010, when it will then be shredded. If
any of your insurance information changes, please contact Steve for a new
release.

I grant permission for the administration of first aid care by the person(s) in charge
of Redeemer’s CYF ministry to (Name of student)
___________________________________________ and the transporting of my
son/daughter/child under my guardianship to and from the ministry location to
qualified physicians for treatment of illness or accidents. I understand that every
effort will be made to promptly notify me in the event of any serious illness or
accident and prior to any major surgery, except when delay in such communication
would endanger life. In the event that I cannot be reached, I hereby give permission
to the physician selected by the adult leadership to hospitalize, secure proper
treatment for, and to order injection, anesthesia or surgery if deemed as necessary
for my son/daughter/child under my guardianship. I also understand that there is no
medical coverage for illness or injuries available through the church or any
sponsoring leaders or group.

Parent/Guardian Signature ___________________________________

Date________________
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Please Print Parent/Guardian Name

_________________________________________________
Address______________________________________________________________________
_
Home Phone _____________________________
Other Emergency Numbers/people
_________________________________________________
Insurance Company (in case of emergency)
__________________________________________
Policy #
______________________________________________________________________
Doctor _____________________________________ Phone
____________________________
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Medical Information
GRADE: Last Name:
It is important for us to know of any specific medical and physical
information about your son/daughter/child under your guardianship to help
insure their safety. Please complete the following:

Name of Student ______________________________________________

A. is allergic to the following foods:

____________________________________________
_______________________________________________________________________
_

B. is allergic to the following medicines:

_________________________________________
_______________________________________________________________________
_

C. will be taking the following medications at the time of the trip:

_____________________
_______________________________________________________________________
_

D. other relevant information:

_________________________________________________
_______________________________________________________________________
_

Parent/Guardian Signature ____________________________________ Date

_______________