I give permission for my minor child to attend Piedmont Friends Fellowship retreats. In

the event of an emergency, I authorize the adult leaders of PFF to act for me to make any and

all decisions for me concerning the medical treatment or hospitalization of my minor child; to

consent to any x-ray examination; medical, dental, or surgical diagnosis; treatment; and

hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate)

licensed to practice under the laws of the state where the services are rendered, either at a

doctor's office or in a hospital. I expect to be contacted as soon as possible. I absolve the adult

leaders from personal liability arising from the exercise of such authority, including any and all

costs, expenses, and charges for medical or hospital care provided by or received from

whomsoever, and costs of transportation related thereto. I affirm that the following insurance

and medical information is complete and correct.

Signature of parent or legal guardian:

____________________________________Date:___________

MEDICAL RELEASE FORM FOR

PIEDMONT FRIENDS FELLOWSHIP (PFF)

Young Friend: _________________________________________Date of birth:_____________________

Parent or legal guardian:_________________________________________________________________

Address:______________________________________________________________________________

Phone numbers during the retreat

(home,work,cell,pager):__________________________________________________________________

Emergency name and phone number, if parent cannot be reached:________________________________

_____________________________________________________________________________________

Insurance company:_____________________________________________________________________

Address:______________________________________________________________________________

Phone number:______________________________ Policy number:______________________________

Policy holder:__________________________________________________________________________

Family doctor (and phone number):________________________________________________________

Prescriptions currently taken (please keep us up-to-date):_______________________________________

Current medical or psychological conditions, etc.:_____________________________________________

Other information that adult FAPs and/or emergency room physician should know:

_____________________________________________________________________________________

_____________________________________________________________________________________

Are there any dietary restrictions/ considerations we should know about when planning meals?

_____________________________________________________________________________________

_____________________________________________________________________________________

PLEASE DON'T FORGET TO FILL OUT PAGE 2 OF THIS FORM!

Page 2 of 2

To the parent,

There may be times when your child suffers from mild symptoms that can be treated with simple

over-the-counter medications that we have available in our first aid kit.

Please take a moment to circle your response to indicate your willingness for your child to receive

the following medications when necessary to make him or her more comfortable (we have provided some

brand names to help you recognize the generic names we have listed):

Yes: __ No:__ Acetaminophen (Tylenol) for pain or fever

Yes: __ No:__ Antihistamine (Benadryl) for itching, colds, or bee stings

Yes: __ No:__ Immodium for diarrhea

Yes: __ No:__ Emetrol for nausea (a sugary syrup that can sometimes help)

Yes: __ No:__ Pink bismuth (Pepto Bismol) for nausea and vomiting

Yes: __ No:__ Topical antibiotic ointment

Information on Tetanus shots

Date last shot:--------

___________ Don't know: ___________Less than 5 years: ______5-10 years:_______

Over 10 years: ___________My child is allergic to tetanus:______________

If there is an accident for which a tetanus shot is recommended, may we authorize it to be given?

Yes: ________No:__________

If your child has asthma, please answer the following questions:

Does your child use a daily medication?

If yes, please list the medication(s) and the dosage(s):

How often does he/she experience an asthma attack?

Has your child ever been hospitalized because of asthma?

Is your child able to recognize and treat the onset of an attack?

Can your child recognize when the attack is severe and requires the attention of medical

professionals?

How should we respond to a breathing problem with your child?

If your child has serious allergies, please answer these questions:

What are the triggers for your child?

Does your child travel with a medication for their own use (ie: Epi-Pen or Primatene Mist)?

What have previous reactions been?