Medical Release Form
Church of the Pilgrimage
8 Town Square Plymouth MA
Name of child(given and preferred)
Gender & pronouns
Name of Parent/guardian & phone number
Name of adult who brings child to church& phone number
Child's physician name & phone number
Child's dentist name & phone number
Emergency contact: name & phone number
learning issues (such as ADD, learning disabilities, developmental disabilities)*
Health History, cont.: please use the space below to fill in details regarding checked boxes with asterisks above. Also, if there is any other pertinent health information, please add that below.
Immunizations: is child up to date on these?
Tetanus: when was child's last tetanus shot?
Surgeries: please provide information on any major surgeries or injuries child has had and approximate dates.
Insurance information: Carrier name & phone, policy number, subscriber name
Statement of Consent: I, the undersigned parent/guardian of the above named child do hereby consent to any x-ray exam, anesthetic, medical diagnosis or treatment and hospital services that may be rendered to my son/daughter, under the general or specific instructions of the on-call physician at a hospital or clinic. It is understood that this consent is given in advance of any specific diagnosis or treatment, and it is given to encourage those persons who have the temporary custody of my child in my absence, and said physician, to exercise their best judgment as to the requirements of such diagnosis or said medical treatment. I understand that my and all medical expenses incurred are my responsibility and that there is not medical coverage provided by The Church of the Pilgrimage of Plymouth, Massachusetts.• This consent will remain in effect for one year from signing unless otherwise specified. Please enter the date and your full name below which will act as your electronic signature.
Administration of Medication Part I: Is your child taking any prescription or over the counter medication on a regular basis? If so, please provide name of medication, dosage and frequency below.
Administration of Medication Part II: Where applicable, can your child be expected to take the right amount of medication at the right time? With your answer, please enter the date and your full name below which will act as your electronic signature.
Administration of Medication Part III: Do you object to routine, over the counter medications such as Tylenol, Benedryl, Tums, etc? With your answer, please enter the date and your full name below which will act as your electronic signature.
Please note: All medications, both prescription and non-prescription, MUST be in the original container and properly labeled. This applies even if your son/daughter has permission to self-administer his/her medications.
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