SALISBURY PRESBYTERIAN CHURCH

YOUTH EMERGENCY FORM

YOUTH NAME: ____________________________________               BIRTHDATE: _________

ADDRESS:   ________________________________________               PHONE#:   _____________

____________________________________________________________________________

LIST TWO PEOPLE TO CALL IN AN EMERGENCY IF YOU CAN’T BE REACHED:

NAME:   ____________________________________________               RELATION:   ___________

ADDRESS:   _________________________________________               PHONE #:   _____________

NAME:   ____________________________________________               RELATION:   ___________

ADDRESS:   _________________________________________               PHONE #:   _____________

DOCTOR: ___________________________________________               PHONE #:   _____________

ALLERGIES/MEDICAL CONDITION:   ___________________________________________

PARENT’S NAME:               FATHER:   _______________________ (W) ___________________

                                          MOTHER:   ______________________               (W)   __________________

MEDICATION CURRENTLY TAKING:               (a)   ____________________________________

(b)   ____________________________________

DOSAGE:                                                                   (a)   ____________________________________

• ____________________________________

RELEASE FORM

I understand that my child will be participating in activities both at the church and at other locations and I support these activities with my prayers.

IN THE EVENT OF ILLNESS AND/OR INJURY INCURRED BY MY CHILD, ___________________________.   I AUTHORIZE THE YOUTH DIRECTOR AND/OR THE YOUTH COUNSELORS AND/OR PARENTS OF THE SALISBURY PRESBYTERIAN CHURCH YOUTH PROGRAM TO CONSENT TO EMERGENCY TREATMENT OR CARE OF MY YOUTH AND TO EXECUTE ANY DOCUMENTS IN MY NAME, PLACE AND STEAD TO ACCOMPLISH THIS PURPOSE.   HOWEVER, THE ADMINISTRATORS OF THE SALISBURY PC YOUTH PROGRAM SHALL FIRST MAKE ALL REASONABLE EFFORTS TO INFORM ME OF SUCH ILLNESS OR INJURY AND OBTAIN INSTRUCTIONS RELATIVE TO THE CARE AND TREATMENT OF SAID MINOR YOUTH.   SAID CARE OR TREATMENT SHALL BE PROVIDED BY A RESCUE SQUAD OR AT THE NEAREST HOSPITAL.   ALSO I GIVE UP THE RIGHT TO HOLD ACCOUNTABLE SALISBURY PREBYTERIAN CHURCH, ADULT LEADERS, OR THE OTHER YOUTH FOR ANY ACCIDENTAL OCCURRENCE.

____________________                         _____________________________________________

DATE                                                             PARENT’S OR GUARDIAN’S SIGNATURE

____________________                         ______________________________________________

INSURANCE COMPANY                      INSURANCE NUMBER

THE YOUTH COUNSELOR IN CHARGE HAS MY PERMISSION TO ADMINISTER THE FOLLOWING:

____________________               Tylenol or non-aspirin pain reliever

____________________               Medication that youth is currently taking

                                                        Name of Medication:   _____________________________

                                                        Dosage:   ________________________________________