Emergency Medical Information and Authorization
For use in the Penn-Del District
Royal Ranger program
Name: __________________________________ Date
of Birth: __________________________
Father's Name ___________________________ Occupation:
_________________________
Mother's Name __________________________ Occupation:
_________________________
Child’s address: __________________________________City:
_______________Zip: _______
Telephone #: ____________________________ Work #: ____________________________
Family Doctor: _____________________________
Phone #_____________________________
Child’s SS#: ________________________________
Date of last Tetanus shot: _____________
Is your child presently being treated for an
injury or sickness? NO_____ YES________ Explain:
_____________________________________________________________________________
Does your child require a special diet?
_______ If YES, Explain__________________________
Does your child take any regular
medications?
_______________________________________
If Yes,
please explain: ___________________________________________________________
Is your child allergic to any type of
medication? _______________________________________
Has your child ever had an operation?
_______________________________________________
Does your child have or has ever had any of
the following?
Seizure Disorders Asthma Heart
Murmur
Diabetes Hay
Fever Kidney
Disease
Does your child have any allergies other than
medications? ______________________________
Can your child swim?
___________________________________________________________
Is there any other information that might be
useful for us to know? ________________________
______________________________________________________________________________
Medical Treatment Authorization
I understand that I
will be notified in the case of a medical emergency. However, in the event that
I cannot be reached, I authorize the calling of a doctor and the providing of
necessary medical services in the event my child is injured or becomes ill. I
understand that the Royal Rangers will not be responsible for medical expenses
incurred, but that such expenses will be my sole responsibility as parent and
/or guardian.
I agree to notify
the church and/or Royal Rangers in the event of any health changes that would
restrict my child’s participation in any normal youth or royal Ranger activity.
I also understand that the adult supervisors reserve the right to restrict my
child from any activity that they do not feel is within the physical
capabilities of my child.
Signature of parent/guardian
_______________________________ Date ___________