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New Jersey Medical Release Form 1

This form is provided by Episcopal Diocese of New Jersey for the medical information release regarding the medical care and treatment necessary to be administered to the child.
New Jersey Medical Release Form 1
New Jersey Medical Release Form 1
Parent/Guardian Emergency Contact
Name(s)_________________________
Home Phone_____________________
Work Phone(s)____________________
____________________
Cell Phone(s) ____________________
__________________
MEDICAL RELEASE FORM – EPISCOPAL DIOCESE OF NEW JERSEY
Youth’s Name and Birthdate:___________________________________________________
The following is a list of medications that my child,
____________________________________, will need
to take while attending __________________________.
(Please attach a list if additional room is needed.) All
prescription medication must be properly labeled in its
original pharmacy container. Over the counter
medication must also have the youth’s name written
clearly on the container.
NAME OF MEDICATION DOSE WHEN TAKEN
___________________________________________________________________________________
___________________________________________________________________________________
Medical Conditions___________________________________________________________________
Food/Drug Allergies__________________________________________________________________
I understand that, except for rescue inhalers and EpiPens, all youth medications will be secured by the
event nurse for the duration of the event and made available for my child to take when scheduled.
___________________________________________________________________________________
Signature of Parent or Guardian Date
The following medication will be available for your child to take with your permission. I, the
parent/guardian of_________________________________ give permission for my child to take:
Cough Drops Yes_____ No_____
Tylenol Yes_____ No_____
Motrin Yes_____ No_____
Mylanta/Titrilac Yes_____ No_____
Benadryl Yes_____ No_____
Imodium A-D Yes_____ No_____
___________________________________________________________________________________
Signature of Parent or Guardian Date
By my signature of this form, I give permission for all licensed medical and emergency personnel to treat
my child, _____________________________, for illness or injury experienced during Diocese of New
Jersey Youth Events. I give permission for event staff, in my absence, to authorize medical or
emergency treatment for my minor child and to pass on to medical or emergency providers the insurance
and medical information provided on these forms.
Medical Insurance Co. ________________________________________________________________
ID# ______________________________________ Group # ________________________________
Primary MD Name _____________________________________ Phone # ______________________
___________________________________________________________________________________
Signature of Parent or Guardian Date
Form Updated 5/30/2012
Please check yes or no for each
of the listed medications.
New Jersey Medical Release Form 1
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