8 - Medical Authorization

Circle of Friends

Medical Information and Release Form & Medication Authorization
Name of child

First NameLast Name
Date of Birth

MonthDayYear
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.
YesNo
If yes, name of Company
Hospital Preference
YesNo
If yes, please explain
YesNo
If yes, please specify
YesNo
If yes, please specify
YesNo
YesNo
Date of Child's last Tetanus shot

MonthDayYear
Date
YesNo
If yes, please explain
YesNo
If yes, please specify
YesNo
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

MonthDayYear
Date
I give representatives of Circle of Friends permission to administer the following medication(s) to my child:
1) Medication
Non-prescriptionPrescription Rx #:
Dose (how much?)
Frequency (how often?)
Time
MouthEarsEyesNoseSkin
Duration Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Reason for medication
Special Instructions
YesNo
The medication listed above was prescribed by
2) Medication
Non-prescriptionPrescription Rx #:
Dose (how much?)
Frequency (how often?)
Time
MouthEarsEyesNoseSkin
Duration Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Reason for medication
Special Instructions
YesNo
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

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