Medical Release Form Second Presbyterian Youth, Louisville, KY

Name of Youth:

Name of Parent(s)/Guardian(s):

Address:

City:

State:

Zip:

Telephone Number(s):

Event: 2023–2024 Youth Group Trips & Event

Dates: All Dates

In the event that ____________________________________ becomes ill or sustains an injury while on an authorized and chaperoned event with Second Presbyterian Church, Louisville, Kentucky, I, the undersigned, give my permission to those in charge to take whatever steps are necessary to stop any bleeding and/or to administer first aid.

I also consent to an X-ray examination, Anesthetic, Medical (or Dental) or Surgical diagnosis and treatment including invasive procedures and hospital care, as well as the administration of drugs or medicine to be rendered to my son or daughter under the general or specialized supervision and upon the advice of a duly licensed physician and/or surgeon.

I understand that this consent will apply to all emergency situations present and future in effect until written revocation is made.

I also assume responsibility for any medical and emergency expenses in the event of accident, injury, or other incapacity, regardless of whether I have authorized such expenses.

Parent or Legal Guardian Signature:

Date Signed:

Insurance Carrier:

Insurance Policy #:

Group Policy #:

Doctor's Name:

Doctor's Phone Number:

Please list any allergies of which we should be aware including allergies to any medicines:

Allergy: Type of Reaction: Necessary Treatment:

Please list any and all medication that the participant will have with them on the trip including prescription and over the counter medication. (Yes, even Tylenol!)

Medication: Purpose: When is it taken?

Please list any injuries (broken bones, strains, etc.), illnesses (flu, etc.) or surgeries that have occurred over the past three to six months:

Injury / Illness / Surgery:

Date:

Please inform us of any special circumstance that would affect your youth emotionally: (Recent illness or death in the family, family or school difficulties, distress, loss, or other emotionally charged situation, etc.)

Does the participant have a history of:

Anxiety?

Yes

Depression?

Yes

Other mental health diagnoses:

Please explain or give details about any of the above conditions:

Please list any additional medical needs or physical difficulties of the participant that would help the adult sponsors from Second Presbyterian Church to care for the participating youth in the best possible way:

All information on this form is confidential and will only be shared, as needed, with the adult leaders and medical professionals.

Medical Release Form Second Presbyterian Youth, Louisville, KY

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