EmailMe Form - Central Baptist Church Special Needs Form

EmailMeForm

Parent/Guardian *
First Last
Child *
First Last
Home Phone *
### - ### - ####
Emergency Phone *
### - ### - ####
My Child's Anaphylaxis Triggers Are
Other (Please Specify)
My Child has a Medical Condition that may require intervention (Please Specify)
My Child's Symptoms Usually Include (Check all that apply)
Swelling (eyes, lips, face, tongue)
Difficulty breathing or swallowing
Cold, clammy, sweaty skin
Flushed face or body
Fainting/Loss of consciousness
Vomiting
Coughing or choking
Stomach cramps, diarrhea
Dizziness/confusion
Other (Please specify)
Change in voice
Symptoms (Other)
My Child's Emergency Treatment Is

Medicine/Dosage

Location of Medicine
Please give detailed instructions for emergency response. Describe the method of administering the medicine as well as the timing and whether or not we should attempt to contact you as a parent before administering the medicine or calling 911. Be as detailed as possible.
This form is to be filled out by parents whose children may require special medical intervention (severe allergies, asthma, seizures, etc.) As a norm, volunteers are not to administer medicines, but with parental authorization, we will administer medicines provided by the parents for their specific child.
Disclaimer/Authorization
A signature will be required on the first day of camp
Due to the potential severity of the situation, I authorize the ministry volunteers and staff of Central Baptist Church to administer medicine to my child as described in this form. I acknowledge that it is my responsibility to provide the medicine and confirm that the specific ministry volunteers caring for my child in each and every separate occasion are aware of these instructions and the location of any medicines. I will in no way hold the ministry volunteer, staff member, or Central Baptist Church responsible for the results of these medical interventions. I understand that those caring for my child will not necessarily have medical training beyond that which I provide. This authorization will remain in force until I notify the church in writing or present revised instructions *
I Agree
Date Time *
MM / DD / YYYY

Medicine/Dosage
Location of Medicine

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Disclaimer/Authorization