Authorization to consent for medical and dental care



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AUTHORIZATION TO CONSENT FOR MEDICAL AND DENTAL CARE

____________________ LUTHERAN CHURCH YOUTH GROUP

Senior High and Junior High Events

January 2014


(I) (We) the undersigned parent(s) and/or natural guardian(s) of _________________________,

a minor, do hereby authorize my child’s Youth Director/Counselor (and/or any other adult appointed or designated by him/her to (i) consent to medical, surgical and dental care for such minor child, (ii) consent to any diagnostic tests, medical, surgical or dental procedure or treatment as may be considered therapeutically necessary by the physician, surgeon, dentist or other health care personnel providing care for such minor child, and (iii) on (my) (our) behalf, to (a) employ physicians, surgeons, dentists, nurses, and other health care personnel as may be deemed necessary for such minor child. (b) admit such minor child to any hospital, clinic, emergency room, laboratory or other health care or diagnostic facility for examination, treatment, surgery or care and (c) sign all necessary consents and authorizations.


It is understood that this authorization is given in advance of the occurrence of any condition or situation which would necessitate any such medical, surgical or dental care being required but is given to provide authority to obtain such care and (c) sign all necessary consents and authorizations.
NAME & RELATIONSHIP OF EMERGENCY CONTACT PEOPLE
_________________________________________________________ ________________

(Guardians Name) (Relationship) (Phone)


________________________________________________________ _______________

(Other emergency contact person) (Relationship) (Phone)


FAMILY DOCTOR: _______________________________ OFFICE PHONE: ______________
MEDICAL EXCHANGE NUMBER: ________________________________________________
FAMILY DENTIST: __________________________________ OFFICE PHONE:____________
FAMILY HEATH PLAN CARRIER: ________________________________________________
NAME OF INSURED ON POLICY: ____________________ ___________________________
Do any pre-certification, notification or other requirements exist with respect to the health insurance

of the participant? If so, please specify:


__________________________________________________________________________
I fully understand the consequences of the foregoing statements and sign the

AUTHORIZATION TO CONSENT FOR MEDICAL AND DENTAL CARE

knowingly, freely and willingly.

Signature___________________________________________ Date:__________________

EMERGENCY MEDICAL INFORMATION FORM
Please complete so that health providers can be aware of your personal health needs.

Must be completed by all participants.


Name of Participant: ____________________________________________________________
Does participant have: (if “yes” explain)
_____ Yes _____ No ALLERGIES?_____________________________________________________

_____ Yes _____ No HEART CONDITION?______________________________________________

_____ Yes _____ No OTHER?________________________________________________________
Is the participant subject to: (If “yes” explain)
_____ Yes _____ No HEADACHES?__________________________________________________________

_____ Yes _____ No SEIZURES?___________________________________________________________

_____ Yes _____ No MOTION SICKNESS?____________________________________________________

_____ Yes _____ No FAINTING?___________________________________________________________

_____ Yes _____ No SLEEP WALKING?______________________________________________________

_____ Yes _____ No UPSET STOMACH?______________________________________________________

_____ Yes _____ No OTHER?______________________________________________________________
Does participant have reaction to: (If “yes” explain)
_____ Yes _____ No BEE STING?___________________________________________________________

_____ Yes _____ No PENICILLIN?__________________________________________________________

_____ Yes _____ No OTHER DRUGS?________________________________________________________

_____ Yes _____ No POISON IVY, OAK, SUMAC?______________________________________________

_____ Yes _____ No OTHER?______________________________________________________________

_____ Yes _____ No Has the participant had any serious illness or surgery within the past ten years?

Please list:____________________________________________________________
____________________________________________________________________

_____ Yes _____ No Does the participant have any condition that would prevent him/her from participating in any Servant Event activities? Please list: ____________________________________

____________________________________________________________________

_____ Yes _____ No Does the participant take any prescription medication? Please list:

____________________________________________________________________

_____ Yes _____ No Are any drugs ineffective in treatment?______________________________________

_____ Yes _____ No Is the participant diabetic? Medication? ______________________________________

_____ Yes _____ No Does the participant have any sight or hearing impairment? _______________________

_____ Yes _____ No Does the participant wear contact lenses? ____________________________________

_____ Yes _____ No Does the participant wear hearing aids? ______________________________________


Blood Type: __________________________ Date of last tetanus shot:_____________________
A CURRENT TETANUS SHOT IS REQUIRED.

Please indicate ANYTHING else that leaders should know to help avoid or deal with any medical situation that might arise: ________________________________________________________________________________


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