8 - Medical Authorization

Circle of Friends

Medical Information and Release Form & Medication Authorization
Name of Child
Date of Birth

MonthDayYear
Date
DOB
Parent/Guardian Name
Parent/Guardian Phone #
Emergency Contact Person #1 (other than Parent/Guardian)
Relationship to Child
Phone Number
Emergency Contact Person #2 (other than Parent/Guardian)
Relationship to Child
Phone Number
Is Child Insured

YesNo
If yes, name of Company
Hospital Preference
Does Child have any special medical problems

YesNo
If yes, please explain
Does the child require a special diet?

YesNo
If yes, please specify
YesNo
If yes, please specify
Is Child allergic to insect bites?

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

YesNo
Date of Child's last Tetanus shot

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

YesNo
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?

YesNo
If yes, please attach a letter from his/her doctor containing the instructions for administering the medication.
I hereby give permission toCoF Mentor (mentor name) or staff and volunteers at Circle of Friends 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

Clear
Today's Date

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

Non-prescriptionPrescription Rx #:
Dose (how much?)
Frequency (how often?)
Time
Duration Start Date

MonthDayYear
Date
Frequency (how often?)

Taken via:MouthEarsNoseSkinEyes
End Date

MonthDayYear
Date
Reason for medication
Special Instructions
Child can self-administer the medication

YesNo
The medication listed above was prescribed by
2) Medication
2 Medication

Non-prescriptionPrescription Rx #:
Dose (how much?)
Frequency (how often?)
Time
Frequency (how often?)

Taken via:MouthEarsEyesNoseSkin
Duration Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Reason for medication
Special Instructions
Child can self-administer this medication

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

Clear
Today's Date

MonthDayYear
Date
Should be Empty: