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Operation Onesimus Medical Form

!Please print out 2 copies. Bring one to camp with you and send the other by mail or scan and email to
Maggie Schlageter:
Maggie Schlageter - 24 Walnut Pkwy Apt 2, Montclair, NJ 07042
!Purposes of this form: To allow parents to authorize medical treatment for children (up to and including
17 years of age) when a parent cannot be reached. To provide information needed by Onesimus staff to
quickly arrange proper medical care for a student.
!Name of minor
Last Name: First Name:
Date of Birth:
!Medical Information
Allergies (food, drug):
Date of last Tetanus shot:
Other pertinent medical information?

!Name of Parents or Legal Guardians

I, , hereby consent to the rendering of Emergency
Department care and such medical treatment as the attending physician or others of the hospitals
medical staff consider to be necessary for my child, , on
and including the dates through , 20 .
!Home Address:
Home Phone: Cell:
Insurance Co & Address:
Policy Number: Group Number:
Name of Policy Holder:
Occupation: Employer:
Other Emergency Contact: Phone:
Family Physician: Phone:
Dentist: Phone:
Medical Specialist: Phone:
Signature of Parent or Legal Guardian: