Microsoft word - cyp 9 - medical history form.doc
2011-12 Medical History, Authorization to Treat,
and Liability Release Form
Good Shepherd Lutheran Church, Woodstock, GA
This form is to be completed at the beginning of each program year. It will accompany leaders and youth when traveling off-
site. Please be sure information is as accurate as possible. Parents are responsible for updating this information as it
changes (i.e. changes to insurance, allergies, medical history, emergency contact information…)
Name_______________________________________________ Age_________ Birth Date____________ Address________________________________________________________________ Zip____________ Please list, in order, three persons that we can contact in the event of an emergency. We will call the first person listed first and continue down the list until we have made contact.
1. Name/relation to child_________________________________________ Phone_________________ 2. Name/relation to child_________________________________________ Phone_________________ 3. Name/relation to child_________________________________________ Phone_________________
Child’s Physician_____________________________________________________ Phone_________________
Child’s Insurance Company_____________________________________________ A copy of your child’s insurance card (front and back) must accompany this form to be complete!
Past Medical History
Asthma_____ Sinusitis______ Kidney______ Heart______ Diabetes______ Seizures_______ GI_______
If you checked asthma, please indicate triggers_______________________________________________
If you checked asthma, will your child carry an inhaler? _____Yes _____No
If you checked any of the others above, please explain
Allergies: Foods___________________________________ Medications______________________________
Insects__________________________________ Poison Ivy, Oak or Sumac____________________
If you checked any of the above, please indicate type of allergic reaction. _____________________________
Does child carry an epi-pen? _____Yes _____No Continued on the back
Past surgeries or serious illnesses (please list):___________________________________________________
History of Childhood Diseases (check all applicable): Chicken Pox______ Measles______ Mumps______
Date of last Tetanus shot or booster:_________________
Is there anything else you would like for us to be aware of relative to your child’s health or past medical history?
Please check the over-the-counter medications that are acceptable for your child to take if he or she requests
_____Ibuprofen (Advil/Motrin/or generic)
_____Antihistamines for seasonal allergies (Zyrtec, Claritin, Allegra, …, or generic equivalents)
Permission for Treatment
The undersigned, as parent/legal guardian of above named child, authorizes Good Shepherd Lutheran Church
staff and/or volunteers and the medical personnel they have selected to consent to any medical/hospital care
deemed necessary. I consent to the release of this health history to the emergency room, hospital or doctor’s
office providing care. Good Shepherd will endeavor, but is not required, to communicate with me prior to
treatment. The undersigned releases Good Shepherd and its designated leaders (staff and volunteer) from any
liability and claims arising from any consent given in good faith and in connections with diagnosis or treatment.
The undersigned certifies that he/she has full authority to sign this Release and Authorization.
_________________________________ ____________________________________ _____________
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