MEDICAL PERMISSION FORM

I grant permission for the administration of First Aid to my child, ______________________________,

by the people in charge of The Cereal Bowl lock-in, and those transporting my child to and from the event as their judgment deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature.  I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life.  In case of medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant.  In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my child.

Print Name: _____________________________________________           Birth Date: ______________                                                                         
                                                (youth)                                                                                    (youth)

Allergic to medication/other?   NO ________               YES ________

 If yes, please describe: _________________________________________________________________

 Medication(s) presently taking: __________________________________________________________

 
Insurance Information

 Policy in the name of: _________________________________________________________________

 Insurance Company: __________________________________________________________________

 Policy Number: ______________________________________________________________________

 Identification Number and/or Social Security Number: _______________________________________

 Authorized Physician: ______________________________________ Phone: (       )________________