MEDICAL AUTHORIZATION FOR TREATMENT OF A YOUTH PARTICIPANT AT NYE08

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I request and authorize the National Youth Event, Knoxville, Tennessee area hospitals, medical staff personnel, agents and employees, to have access to information contained in this form and to provide all medical care, routine tests, treatment and necessary transportation advisable for the health of my child. I acknowledge that no representations, warranties or guarantees as to result or cures will be made. I hereby give permission to medical staff to secure and administer treatment including hospitalization for my child named below.

The name of the child covered by this authorization is:

Name: ________________________________________________________________________________

Parent/Legal Guardian: __________________________________________________________________

Home Address: __________________________________ City: _________________________________

State: ____________________ Zip: _____________ Home Phone: ___________________________

Business Address: ________________________________ City: __________________________________

State: ____________________ Zip: _____________ Work Phone: ___________________________

Signature: ______________________________________________ Date: ________________________

Witness: _______________________________________________ Date: ________________________

In Case of Emergency Contact:

Name: _________________________________________ Day Phone: ___________________________

Evening Phone: _________________________________ Cell Phone: ___________________________

Health Care Information

Name of Dentist/Orthodontist: _______________________________ Phone: ______________________

Name of Family Physician: _________________________________ Phone: ______________________

Does you carry family medical/hospital insurance? Yes No

If so, indicate: Carrier: ____________________________ Policy/Group# _________________________

Date of last Tetanus shot? _________________________

Is your child under the care of a physician?

Epilepsy Yes No ..........................................Diabetes Yes No

Other: ______________________________

Recommendations and Restriction while at NYE 2008, June 23-28, 2008

Any medications to be administered at National Youth Event 2008 and specific dosages: Yes No
If yes, please specify: ____________________________________________________________________

Any allergies (drugs, food, plants, insects, etc.) Yes No
If yes, please specify: ____________________________________________________________________

Please list any over the counter medication NOT to be dispensed to your child: _________________
______________________________________________________________________________________

Additional health information (surgery or serious injuries, chronic or recurring illness/medical conditions,
psychiatric counseling or indications, etc.) ___________________________________________________