Medical Consent Form
Parent/Guardian work phone___________________________
Emergency and Health Information Does youth have . . . (if “yes” please explain) _____yes _____no
Allergies? ___________________________________________________________
Heart condition? ______________________________________________________
Other? ______________________________________________________________
Is youth subject to . . . (if “yes” please explain)_____yes _____no
Fainting? ___________________________________________________________
Sleep walking? _______________________________________________________
Upset stomach? ______________________________________________________
Motion sickness? _____________________________________________________
Other? ______________________________________________________________
Does youth have a reaction to . . . (if “yes” please explain)_____yes _____no
Bee sting? ___________________________________________________________
Penicillin? __________________________________________________________
Other drugs? _________________________________________________________
Poison ivy, oak, sumac? ________________________________________________
Other? ______________________________________________________________
Please indicate anything else leaders should know to help avoid or deal with your youth’s health. ________________________________________________________________________________________________________________________________________________________________________________
Date of last tetanus shot _______________________Insurance Co. _______________________________________ Policy # __________________________Name of policy holder ____________________________________________________________________Pre-cert: _____yes _____no If yes, phone number _____/_____-_______Doctor’s name _________________________________________ Phone _____/_____-_______You have permission to give my youth:
___yes ___no robitussin (cough medication)
___yes ___no solarcaine spray/lotion/ointment
Emergency procedure: in the event of any emergency leaders will attempt to first contact parent/guardian/doctor! If this is not possible, note below: ___yes ___no
1. With my signature I hereby authorize First Aid by staff or youth workers.
2. With my signature I hereby authorize emergency medical care by hospital staff and or doctor selected by church
3. With my signature I hereby authorize doctor selected by church staff or youth worker to hospitalize, secure
treatment for, and to order injection, anesthesia, blood transfusion or surgery. If parent/guardian has answered “NO” to any of the above, parent/guardian must indicate procedure to be followed in the event that parent/guardian is unable to be contacted. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
Full Name:______________________________________________ Address: _______________________________________________________________________ Suburb: ________________________________________________ Telephone No. (H): ___________________(W)_________________ (M) ____________________ Email address: __________________________________________________________________ No. of hours you work each week:
ist auch mit zahlreichen klinischen Studien belegt. Diese Studien zu zitieren ist aber oft ein rechtliches Adaptogene sind Natursubstanzen, die dem Körper Problem – Jiaogulan ist kein Heilmittel und darf, wie dabei helfen, sich an Stresssituationen anzupassen so vieles aus der Natur, nicht mit Wirkungen in und einen positiven Effekt bei stressinduzierten Zusammenhang gebracht werden. Aus