Emergency Medication Consent Form

Emergency Medication Consent Form

Vacation Bible School 2025, hosted by Pathhope International Inc. and House of Restoration and Healing Church. This form authorizes your child to carry and self-administer emergency medication such as an inhaler or EpiPen during VBS.
Child's Full Name*

First NameLast Name
Medication Name*
Condition Being Treated*
Dosage and Instructions*
Frequency/When Used*
Medication Expiration Date*

MonthDayYear
Date
Is your child trained and capable of self-administering this medication?*
Will your child carry this medication with them during VBS hours?*
I authorize my child to carry and self-administer the emergency medication listed above during Vacation Bible School. I understand that VBS staff and volunteers will not administer, store, or monitor this medication. I release Pathhope International Inc. and House of Restoration and Healing Church, Inc. from any liability related to its use or misuse.
Parent/Guardian Full Name*
Phone Number*
Signature*

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Date*

MonthDayYear
Date
Should be Empty: