Surge Encounter 2020 Medication Permission
Complete One Form Per Student. To be completed by parent/guardian
Email address *
Student Name *
Gender *
Church Attending With *
Parent/Legal Guardian Name and Preferred Phone # *
Emergency Contact
Please list an emergency contact name and phone number other than Parent/Legal Guardian.
Emergency Contact Name *
Emergency Contact Phone Number *
AUTHORIZATION, WAIVER, AND RELEASE
I give permission for Burn Adult Leaders to give or apply the below listed medication(s)
to my child as follows: (specify medication, prescribed medication, over-the-counter product)
Medication List
Note: If the medication for this child is prescription, it must be in the original prescription container and also properly labeled including the prescribing physician’s name and contact information.
Medication 1 Name *
Date to be given *
MM
/
DD
/
YYYY
Date to stop *
MM
/
DD
/
YYYY
Time to be given *
Time
:
Dosage *
Storage *
Medication 2 Name
Date to be given
MM
/
DD
/
YYYY
Date to stop
MM
/
DD
/
YYYY
Time to be given
Time
:
Dosage
Storage
Parent or Legal Guardian Name *
Date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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