Health and permission form 2014

LifeBridge Church Amplify Student Ministries Health and Permission Form
The following must be completed in full before your student can go on any student ministry
trip.
!Student’s Name __________________________________Grade______ School _________________________ !Address ______________________________________ City_______________ State______ Zip_____________ !Parents’ Names _________________________________________ Home Phone __________________________ !Person to Contact in Case of Emergency______________________________ Emergency No. _______________ !Health Insurance Carrier____________________________________ Group No.__________________________ !Name Insurance is in __________________________________________________________________________ !Does insurance company need to be contacted in case of medical care or treatment?_________________________ !If so, what is the phone number?__________________________ !Physician’s Name _________________________________ Physician’s Address ___________________________ !Physician’s Phone Number ______________________________ !Allergies: Medications _____________________________________________________________________ Foods__________________________________________________________________________ !Prior Health History (include age or date): Previous Surgery _________________________________________________________________ Serious Diseases or Health Conditions of which we should be aware_________________________ _______________________________________________________________________________ !!!Approved Medications My child may be administered the following over the counter medications by the LifeBridge staff and Volunteers. Please check ALL that apply. (If not on the list and your child takes regularly, please give the nurse enough for your child while on the trip.) Headache/Pains/Cramps
Diarrhea
Stomach/nausea
Motion sickness
Cough/congestion
!LifeBridge Church Amplify Student Ministries Current Medications Form Please list any medications your student is taking that will need to be administered while on the trip (include name of medication, dosage, and when to be administered along with the name of the prescribing physician.) All medications must be in the original prescription bottle and labeled with the name of the student and directions for administration. All medications to be administered must be in a zip lock bag labeled with the student’s name and turned in to !Doctor____________________________________________________________ MEDICATION
!********************************************************************** !!__________________________________ has my permission to attend the LifeBridge Church Amplify Student Ministry events during the calendar year January 1, 2014 - December 31, 2014. I give LifeBridge Church sponsors permission to permit medical attention in case I cannot be notified. I further relieve LifeBridge Church and its sponsors of any liability. !!Parent’s Signature ________________________________ Date _____________________

Source: http://www.signupforbigstuf.com/wp-content/uploads/2014/01/Health-and-Permission-Form-2014.pdf