Emergency Form

Trumbull North Catholic Community

Emergency Medical Authorization Form

Child Information

Name

First

Last

Church at which your child will be attending Faith Formation

Layout Layout Additional

Date of Birth

Grade Level

Gender

Home Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Primary Emergency Contact

Name

Home Phone

Cell Phone

Relationship to child

Work Phone

Email Address

Secondary Emergency Contact

Name

Home Phone

Cell Phone

Additional Contact(s)

Relationship to child

Work Phone

Email Address

Name

Phone Number

Relationship to Student

Email Address

Medical Information

Known Allergies

Special Needs

Primary Care Physician

Preferred Dentist

Preferred Hospital

Other information pertinent to the health/safety of your child

Medications

Other

Physician Phone Number

Dentist Phone Number

Consent and Acknowledgement

Permission for Emergency Medical Care (Required)

I authorize parish officials to obtain emergency medical care for my child if necessary. In the event reasonable attempts to contact me through the above listed contact numbers have been unsuccessful, I hereby give my consent for the above listed preferred physicians, or in the event that they are not available, by another licensed physician. This authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists concurring in the necessity for such surgery are obtained before surgery is performed.

Additional Information

I wish to inform you that additional medical information and the recommended course(s) of action (allergies, dietary restrictions, special conditions, etc.) are detailed on a separate printed sheet and will be provided to the authorized parish officials.

Special Request

I would like to have a member of the program staff speak with me further regarding a medical concern or situation. Please contact me at your convenience.

[Grade 7-12 Only]

I hereby grant permission for nonprescription medication (such as acetaminophen, decongestant, cough syrup) to be given to my son/daughter, if requested by my son/daughter and deemed advisable by an adult chaperone.

[Grade 7-12 Only]

My son/daughter is taking medications at present. He/she will bring all necessary medications and such medications will be well labeled. The names of and the concise directions for taking such medications, including dosage and frequency of dosage will be provided to authorized parish officials.

Enter your name to confirm Consent and Ackowledgement of this Medical Authorization:

Date of Signature