8 - Medical Authorization

Circle of Friends

Medical Information and Release Form & Medication Authorization

Name of child

First NameLast Name

Date of Birth

Date

DOB

Parent/Guardian Name

First NameLast Name

Parent/Guardian Phone #

Format: (000) 000-0000.

Emergency Contact Person #1 (other than Parent/Guardian)

Relationship to Child

Phone Number

Format: (000) 000-0000.

Emergency Contact Person #2 (other than Parent/Guardian)

Relationship to Child

Phone Number

Format: (000) 000-0000.

Is Child Insured

If yes, name of Company

Hospital Preference

Does Child have any special medical problems

If yes, please explain

Does child have any drug or food allergies?

If yes, please specify

Does the child require a special diet?

If yes, please specify

Is Child allergic to insect bites?

If yes, does Child have an insect bite kit for emergencies?

Date of Child's last Tetanus shot

Date

Does Child have any medical conditions that would require a paramedic?

If yes, please explain

Is Child taking any medication? (including non prescription drugs)?

If yes, please specify

Does Child take any medication that requires adult supervision?

If yes, please attach a letter from his/her doctor containing the instructions for administering the medication.

I hereby give permission to Circle of Friends staff and volunteers to seek medical attention for my child and give permission to the physician to hospitalize, secure treatment for and to order injections, anesthesia or surgery for my child, as named above, according to the medical standards and expertise then and there available whether known or unknown. In care of any emergency the parent/guardian will be contacted first if at all possible.

Parent/Guardian Signature

Today's Date

Date

I give representatives of Circle of Friends permission to administer the following medication(s) to my child:

1) Medication

1 Medication

Dose (how much?)

Frequency (how often?)

Time

Taken Via:

Duration Start Date

Date

End Date

Date

Reason for medication

Special Instructions

Child can self-administer the medication

The medication listed above was prescribed by

2) Medication

2 Medication

Dose (how much?)

Frequency (how often?)

Time

Taken via

Duration Start Date

Date

End Date

Date

Reason for medication

Special Instructions

Child can self-administer this medication

The medication listed above was prescribed by

I understand that I am: (1) Responsible to provide this medication and maintain the supply as needed, and (2) To notify Circle of Friends in writing of any changes. By signing this form, I hereby release Circle of Friends from any liability regarding any adverse reactions to the above medication(s This authorization applies only to the medication(s) listed above and for the duration of treatment. This also authorizes an exchange of information, as necessary, between the Friend, appropriate Circle of Friends personnel, and/or my child's health care provider.

Parent/Guardian Signature

Today's Date

Date

*This authorization will remain valid until high school graduation of the above-named or the parent/guardian revokes this authorization form in writing.