Junior High Yearly Meeting Retreats Health and Safety Form

Junior High Yearly Meeting Retreats
Health and Safety Form

Please complete and send this Health and Safety Form. We must have this Form on file for each child on retreat. Unless information changes, you do not need to complete a new Health and Safety Form for each retreat.

Please complete and submit one form per child from the same family.

Date of this Form:
Child's Name:
Date of Birth:	(month/day/year)
Home Phone:	(Please include Area Code)
Cell Phone:	(Please include Area Code)
Back Up Phone
Address:	(Number and Street)
City/Town:
State:
Zip Code:
First Parent's Name:
Second Parent's Name:
In case of emergency, name of relative of trusted friend whom we could contact:	Friend's Phone: Relationship to child:
Allergies, food allergies, limitations or health issues for us to be aware of. If "none" please type "none."
Is your child taking any prescribed medications? If so, please explain:
If taking any form of medication, does your child have your permission to self-dose?	Taking no medications. Has permission to self-dose. Needs assistance/reminder
HMO/Insurance Name:
Policy Number:
In case of emergency, I give permission for my child to receive emergency medical treatment. I understand that I will be contacted immediately. Please check one: Give permission Decline permission

Please review info and submit. Health and Safety Form information is considered strictly confidential. Records are maintained by Gretchen Baker-Smith, Coordinator. Please call if you would like to speak about a health issue with Gretchen privately. 508-997-0940.