PARTICIPANT HEALTH FORM

Please complete the form with all medications (prescription, over-the-counter, vitamins) that will be brought to Augustana’s event(s). Ensure that dosages and instructions are accurate.

I approve the over-the-counter medications above for use as needed by the participant. I have crossed off medications that are not approved for use by said participant. I hereby request and give my permission to the Augustana Lutheran Church health care worker to administer medication to the participant identified above. I understand that all medications must be provided in the original pharmacy labeled container. I understand my child assumes responsibility for going to the health clinic at specified times for medications. I hereby give my permission to Augustana Lutheran Church to give care to the participant identified above in case of illness or injury and understand Augustana Lutheran Church will attempt to contact me in such event. Augustana Lutheran Church and its staff have authorization to obtain medical treatment and procedures for the participant as may be appropriate in emergency circumstances, including treatment by physicians, hospital and clinic personnel, and other appropriate healthcare providers.

By pushing the submit button, I am verifying that the information I have provided is true to the best of my knowledge.