Parental Authorization and Medical Release Form
Please fill out one form per child who wishes to attend our Youth Equipping Event on 2/20/21. Thank you!
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Student's Name *
Student's Age *
Address *
City and Zip *
Home Phone Number *
Personal Physician's Name *
Personal Physician's Phone Number *
Insurance Coverage *
Policy Number *
Emergency Contact #1 Name *
Emergency Contact #1 Phone Number *
Emergency Contact #2 Name *
Emergency Contact #2 Phone Number *
Date of last tetanus immunization *
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Immunizations are current? *
List any food or drug allergies (enter n/a if there are none) *
Health History (check all that apply) *
Required
Any condition requiring medication, treatments or restriction from activities: *
My child will need to be given a prescription medicine while in your care. NOTE: all medications must 1. Be in the original container. 2. Have a note with HOW, WHEN, and WHY to administer that is SIGNED by the legal guardian. *
Occasionally, it is necessary to provide youth with non-prescription medications. Please check below to indicate whether you give permission for the listed medication to be administered by qualified staff.  We will NOT be able to administer any medication without this authorization. Please check all that you give permission for. *
Required
In case of an emergency, I hereby give permission to any licensed physician and hospital selected by a member of the CEF® staff to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medical Practice Act. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of my (our) aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment of hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. Typing your name below serves as an electronic signature. *
Today's Date *
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If you have any further questions, please enter them below or email us at centralcoast@cefnorcal.org
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