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It requests answers about physical defects or illnesses, allergies to drugs/medicines, other allergies, current medications or diet/exercise restrictions, last tetanus/diphtheria booster date, and any emotional or social disabilities. 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It also asks for the date of the last tetanus/diphtheria booster shot and any emotional/social disabilities to be aware of.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What emergency contact details are required?",{"text":114,"@type":110},"The form requires names and telephone numbers to call in an emergency, including parent/guardian contacts for home, work, and cell, and additional other emergency contacts with home/work/cell as applicable.",{"name":116,"@type":107,"acceptedAnswer":117},"What permissions does the parent or legal guardian provide?",{"text":118,"@type":110},"The signer authorizes program agents to seek and secure needed first aid or emergency medical treatment, including hospitalization if necessary, and to allow attending physicians and medical personnel to administer needed treatment including surgery. 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Does the child have any known physical defect or illness which might interfere with his/her participation in strenuous activity? If so, please explain.  \n2. Does the child have any allergies or reactions to drugs or medicines? Explain.  \n3. Does the child have any other allergies? Explain.  \n4. Is the child presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc. ) .  \n5. Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)    \n6. Are there any emotional/social disabilities that would be helpful for us to be aware of?  \n7. Is your son/daughter living with   both parents   one parent   guardian   other  \nHealth Insurance Information  \nPolicy Holder’s Name   Insurance Company   Policy Number   Phone Number   Medical Doctor   Phone Number    \nEmergency Contacts  \nName of persons and telephone numbers to call in case of emergency:  \nParent/Guardian   Home  Work  Cell    \nParent/Guardian   Home  Work  Cell   Other   Home  Work  Cell    \nOther Information  \nOther information leaders should know about the child participant:  \nFirst Aid and Emergency Medical Treatment  \nI recognize that there may be occasions where the child named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of this program to seek and secure any needed medical attention or treatment for the child named above including hospitalization, if in the agent’s opinion such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment.  \nI give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.  \nI give permission to transport the child named above to a medical treatment center in a non-emergency vehicle in a medical emergency situation.  \nSignature of Parent or Legal Guardian Date  \nPrint Name of Parent or Legal Guardian  \nWitness Signature Date","cbCaikSaCqyQpj3T","https://ap.wps.com/l/cbCaikSaCqyQpj3T","pdf",80903,"English","# Medical Information for the Child\n## Medical History\n## Health Insurance Information\n## Emergency Contacts\n## Other Information\n# Authorization and Signatures\n## First Aid and Emergency Medical Treatment\n## Signature of Parent or Legal Guardian","[{\"question\":\"What medical history questions does the form ask for?\",\"answer\":\"It asks whether the child has any physical defects or illnesses that could interfere with strenuous activity, allergies to drugs/medicines, other allergies, and whether the child is taking medications or has diet/exercise restrictions. It also asks for the date of the last tetanus/diphtheria booster shot and any emotional/social disabilities to be aware of.\"},{\"question\":\"What emergency contact details are required?\",\"answer\":\"The form requires names and telephone numbers to call in an emergency, including parent/guardian contacts for home, work, and cell, and additional other emergency contacts with home/work/cell as applicable.\"},{\"question\":\"What permissions does the parent or legal guardian provide?\",\"answer\":\"The signer authorizes program agents to seek and secure needed first aid or emergency medical treatment, including hospitalization if necessary, and to allow attending physicians and medical personnel to administer needed treatment including surgery. It also permits transporting the child to a medical treatment center in a non-emergency vehicle during a medical emergency.\"}]","Medical Treatment Authorization Form - Appendix B - Minors - medical treatment authorization form | PDF"]