Emergency Permission and Health Form

* indicates a required field
Name of Participant*
Age*
E-mail*
School*
Grade*
Should be stricken in any way, accident or otherwise, and in the opinion of the counselors in charge, should emergency treatment be required, you have my permission to seek medical help, including surgery, which in your judgement is competent, during the
Name of Acitivity: Date of Activity:
The youth named above is covered under hospitalization insurance with Company, policy no. in the name of .
In case we are unable to contact you in an emergency, whom should we contact next?
Name Phone
Family Physician
Please answer me these questions three (to the best of your knowledge) regarding the youth named above:

1. Any allergy to medications, food, insect stings, etc.?

2. Does (s)he take any medications routinely? If yes, list the names of each medication, their strength, and dosage schedule.

3. Are there any other particular medical conditions which should be known?
Your Name Home Phone
Work Phone Cell Phone

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