CATHOLIC CHARITIES – DIOCESE OF METUCHEN CONNECTIONS PROGRAM CHILD/YOUTH MEDICAL INFORMATION Child/Youth: ______________________________________________ D.O.

B: _________________ Parent/ Guardian: ___________________________________________ Phone: __________________ Address: ___________________________________________________ Cell: ___________________ Name of Insurer: ____________________________________________ Policy #: ________________ Emergency Contact: Name ___________________________________ Phone: ___________________ Relationship to Child/Youth: __________________________________ Cell: ____________________ Does your child have any health problems? If so, please describe on the reverse side. Please list: Allergies to Food Allergies to Medicine

MEDICATIONS
Name How Much (dose) How Often (per day) Reason Start Date

Child/Youth’s Physician’s Name: ______________________________________________________ Address: ______________________________________________________ Phone:_______________ I authorize _______________________________ to transport _______________________ for planned activities while _______________________ is in the care of __________________________. If any emergency occurs, every effort will be made to reach the parent/guardian. If all efforts fail, I consent to any and all medical and surgical treatment, including hospital admission, examinations and diagnostic procedures, anesthetics, transfusions and operations, which in the event of an emergency are deemed necessary by the competent medical clinicians to save the life or preserve the health of the above named client. Furthermore, I grant permission for the adult volunteer or staff member to sign for medical/surgical treatment and recognize the adult volunteer or staff member will not assume personal responsibility, including payment for medical attention. I also approve the release from the case records of any medical history or other medical data which would be necessary for the physician and/or hospital to administer such treatment. It is understood that the general consent is applicable specifically and exclusively to emergency situations which occur when I am not available to give consent. I also request that I be notified at the earliest time regarding what treatment was rendered. ________________________________ _____________________________ __________________ Parent/Guardian Jeanette Nadonley/Rosi Pena Date

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