Surge Encounter 2019 Medication Permission
Complete One Form Per Student. To be completed by parent/guardian
Email address *
Student Name *
Your answer
Gender *
Home Church
Your answer
Parent/Legal Guardian Preferred Phone # *
Your answer
Emergency Contact
Please list an emergency contact name and phone number other than Parent/Legal Guardian.
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
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 *
Your answer
Date to be given *
MM
/
DD
/
YYYY
Date to stop *
MM
/
DD
/
YYYY
Time to be given *
Time
:
Dosage *
Your answer
Storage *
Your answer
Medication 2 Name
Your answer
Date to be given
MM
/
DD
/
YYYY
Date to stop
MM
/
DD
/
YYYY
Time to be given
Time
:
Dosage
Your answer
Storage
Your answer
Parent or Legal Guardian Name *
Your answer
Date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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