Youth Medical Form - Strings Without Boundaries

Parent/Guardian's Email Address

Child's Name*

First Last

Parent's Email Address:

Birth Date for Registrant*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

This address form might confuse you because it provides a box for the address below the word “Address” but the zip code should go in the box above the phrase “zip code.” So much for automated technology… Well, at least you don’t have to fill out a form by hand!

Mother's Name*

First Last

Best phone number to call in case of emergency:

Work Phone*

Father's or Partner's Name*

First Last

Address if different from child:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Best phone number to call in case of emergency:*

Work Phone*

Name of Physician or Clinic:*

Phone

Name of Dentist:*

Phone*

Name of Insurance Company:*

Policy Number:*

Policy Holder's Name*

Group Number:

Emergency Contact (other than parents)*

First Last

Relationship:*

Emergency Contact Address:

Street Address Address Line 2 City State ZIP Code

Emergency Contact Phone*

Date of last Tetanus Shot:*

Please list special medical conditions and other medical information. Please include food allergies, medicines, insect bites/stings, asthma, diabetes, epilepsy, seizures, etc.*

Number each medical condition to create an easy-to-read list. Or type “none.”

Medications:*

Please list any medications that may need to be administered during the camp along with instructions for administration. Here is an example: 1. antibiotic (name of antibiotic): 1 pill after breakfast, 1 after dinner. 2. Asthma medication (name of medication): Only to be used when needed. Etc. OR TYPE “NONE”

Medical Treatment Consent for Minors:

Medical Treatment Consent for Minors If your child will be under age 18 while at Strings Without Boundaries on the Williston Northampton School campus. It is camp policy to secure your consent for medical treatment or medication distribution and for the use of medical devices. All medications must be in a medicine bottle and labeled with the camper’s name, doctor’s name and phone number, medication name, and dosage. Also, please complete the following for each medication: Emergency medications such as inhalers, bee sting kits, or insulin may be kept with the student. All other medications will be stored by the director of the Youth Program or, if you’re staying overnight with your child, you will keep it in the shared dorm room.

I give permission …*

For my child to receive medical treatment in case of emergency.

Emergency Consent*

I hereby authorize the treatment, administration of anesthesia and surgical treatment(s) for my minor child in the event of an emergency medical situation occurring during my absence or when the hospital physician(s) are unable to contact me. This authorization extends to any hospital and both physician and nursing personnel within the hospital as well as any physician where treatment is rendered in the physician’s office. I release from medical responsibility and liability, the hospital, medical authorities, and physicians for performing medical procedures acting on the authority of this medical treatment consent form that are deemed necessary for my minor child.

Minor child's name:*

Electronic Signature of Parent or Legal Guardian*

First Last

I understand that typing my name where indicated will carry the same legal weight as a signature.

Date*

Strings Without Boundaries MEDICAL FORM

Medical Treatment Consent for Minors: