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Authorizes a qualified, licensed physician to provide necessary and appropriate treatment after reasonable efforts to reach the guardian. Captures student identity, activity or school year release purpose, parent contact and family physician details, health insurance data, allergies/medications, and permission for specific over-the-counter medications. 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This authority is granted only after a reasonable effort has been made to reach me.  \nStudent’s Name: ______________________________________Relationship to you: _____________________  \nAddress: _______________________________________  \nType of activity or school year for which release is intended: YOUTH GROUP EVENTS 2014-2015  \nPARENT/LEGAL GUARDIANS  \n\n| Father | Address | Phone |\n| --- | --- | --- |\n| Mother Address Phone\u003Cbr>Where parents can be reached:\u003Cbr>Father:  \u003Cbr>Address Phone\u003Cbr>Mother:   Address Phone\u003Cbr>Family Physician:   Phone:   Address:   City:  \u003Cbr>List of allergies, medications, or pertinent comments: |  |  |\n\nHealth Insurance Data:  \nCompany:   Policy:   Group:   Contract:    \nList a neighbor or close relative who will assume care of your child if you cannot be reached.  \nName:   Phone:   Address:   Relationship:    \nI further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. This authorization form is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.  \nDate:   Signed:    \n(Parent or Guardian)  \nThis medical form will be kept on file from June 2023 through August 2024 YOUTH GROUP, CONFIRMATION & Middle School Ministry  \nParents are responsible to notifying the office with any changes  \nADDITIONAL MEDICAL INFORMATION  \nFather’s Cell phone:   Mother’s Cell phone:   Father’s Office phone:   Mother’s Office phone:    \nPlease check and initial those items below that we may give to your child without contacting you. Note that we will not give your child any of the following unless you have checked and initialed the item/s below or given us written authorization (no verbal permission) .  \n Tylenol   Advil    Motrin   Aleve   \n(Check) (Initial) (Check) (Initial) (Check) (Initial) (Check) (Initial)  \n  Benadryl   \n(Check) (Initial)  \nIf your child had any medical condition or allergies such as asthma, seizures, food allergies, environmental allergies or any others that may cause a trigger reaction, please list the severity. Please identify triggers that will help us keep your child safe, list warning signals, and steps you would like us to take in case of an episode:  \n__________________________________________________________________________________________  \n__________________________________________________________________________________________  \n__________________________________________________________________________________________  \n__________________________________________________________________________________________  \nPlease tell us any other information you would like us to know about your child. PLEASE KNOW THAT ALL AND ANY INFORMATION GIVEN WILL BE KEPT CONFIDENTIAL.  \n\n|  |\n| --- |\n|  |\n|  |\n\n(Parent/Guardian signature) (Date","cbCaiqiVt4sDJP5F","https://ap.wps.com/l/cbCaiqiVt4sDJP5F","pdf",84248,"English","# MEDICAL TREATMENT AUTHORIZATION FORM\n## Authorization Statement and Student Details\n## Parent/Guardian Contacts and Physician Information\n## Health Insurance and Additional Medical Information\n## Medication Permissions and Allergy/Trigger Information\n## Signature and Date","[{\"question\":\"How is the form used to manage medications and allergies?\",\"answer\":\"Guardians indicate which medications the ministry may provide without contacting them by checking and initialing items, and they list allergies, medications, and trigger-related severity plus steps to take during an episode.\"}]","Medical Treatment Authorization Form - Parent/Guardian | PDF",1789633930]