OYo Medical Release Form

OYo Medical Release Form

Provide your child’s details and medical information, and confirm consent to treat in an emergency.
Parental Consent for Medical Treatment
With the increasing complexity and sophistication of medical systems, it necessary to have parental consent forms in the unlikely event of some injury or illness to youth involved in congregational events.
Child's Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Permission To Receive Acetaminophen (Tylenol)
I give my child permission to receive Acetaminophen (Tylenol) for minor aches, headaches, pain, cramps, and fever higher than 101 degrees.
Permission To Receive Ibuprofen (Motrin, Advil)
I give my child permission to receive Ibuprofen (Motrin, Advil) for minor aches, headaches, pain, cramps, and fever higher than 101 degrees.
ADMINISTERING MEDICATION PERMISSION
Medication(s) my child needs or might need while out of my care. PLEASE SEND AN AMPLE SUPPLY OF YOUR REGULAR MEDICATION WITH YOUR CHILD TO THE EVENT. SEND ALL PRESCRIPTIONS IN ORIGINAL, LABELED CONTAINER!
My child has medication they need to take (or be ready to take) during this trip/event.
Name of medication that needs to come with my child for this trip/event
MEDICAL HISTORY OF THE CHILD
Please check all that apply:

Other
If other, please indicate what:
If any of the above conditions needs further explanation, please indicate that below.
Any conditions an attending physician might need to be aware of (contact lenses, false teeth, etc.) or any other information that would be important or helpful to youth leaders.
Family Doctor's Name

First NameLast Name
Family Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Insurance Provider (if applicable)
Medical Insurance Policy Number (if applicable)
MEDICAL RELEASE TERMS AND CONDITIONS

I, {q4_fullname2}, hereby grant permission for the Ohev Youth Leaders or chaperones to take whatever steps may be necessary to obtain emergency medical care if warranted for my child, {q2_fullname0}. These steps may include, but are not limited to, the following:

1) Attempt to contact a parent or guardian.

2) Attempt to contact you through any of the persons listed on the emergency information form you completed for us.

3) If we cannot contact you or the child’s physician, we may do any or all of the following:

a. call a physician,

b. call an ambulance,

c. have the child taken to an emergency hospital in the company of a youth leader or chaperone

I, the undersigned parent/guardian of said child, do hereby release, acquit, discharge, and covenant to hold harmless and indemnify Ohev Yisrael Messianic Jewish Congregation or affiliate for any and all claims, demands, damages, injuries, costs, suits, or causes of action, past, present, or future arising out of any accident or sickness, or treatment thereof, by me or my child while participating in any Ohev Yisrael Messianic Jewish Congregation or affiliate program, event, or activity.
I agree to the above Medical Release Terms and Conditions
Please type your name to serve as your signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

OYo Medical Release Form

Parental Consent for Medical Treatment

Permission To Receive Acetaminophen (Tylenol)

Permission To Receive Ibuprofen (Motrin, Advil)

ADMINISTERING MEDICATION PERMISSION

MEDICAL HISTORY OF THE CHILD