Fillable [INSERT CHAPTER NAME] Rhosebud Health Information and Authorization (Constant Contact)

Fill Online, Printable, Fillable, Blank [INSERT CHAPTER NAME] Rhosebud Health Information and Authorization (Constant Contact) Form

Use Fill to complete blank online CONSTANT CONTACT pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

[INSERT CHAPTER NAME] Rhosebud Health Information and Authorization (Constant Contact)

On average this form takes 25 minutes to complete

The [INSERT CHAPTER NAME] Rhosebud Health Information and Authorization (Constant Contact) form is 3 pages long and contains:

  • 2 signatures
  • 10 check-boxes
  • 88 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Constant Contact forms online.

BROWSE CONSTANT CONTACT FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
[INSERT CHAPTER NAME]
Rhosebud Health Information and Authorization Form
1
INSTRUCTIONS: This form must be completed annually, and as changes occur, by the child’s Parent or Guardian and
returned to the Advisor of the [INSERT CHAPTER NAME] Rhosebud Club prior to attending the first Rhosebud
Meeting/activity. Additional sheets may be used, if needed.
APPLICANT’S INFORMATION
Last Name: ______________________________ First Name ___________________________ Middle Name______________________
Address:_____________________________________________________________ City:_________________ State: Zip:
Date of Birth: ___________________________________________________ Age:_______________
PARENT/GUARDIAN INFORMATION
Full name of Parent/Guardian 1:
____________________________________________________________________________________
Address (if different than child’s):
___________________________________________________________________________________
Phone 1: ___________________________ Phone 2: ____________________________ Phone 3:
E-mail: _______________________________________________________________________________
Full Name of Parent/Guardian 2:
____________________________________________________________________________________
Address (if different than child’s):
________________________________________________________________________________
Phone 1: ___________________________ Phone 2: ____________________________ Phone 3:
E-mail: _______________________________________________________________________________
EMERGENCY CONTACTS (If different than above)
Name: Relationship:
Phone 1: ___________________________ Phone 2: _________________________ Phone 3: ________________________________
Name: Relationship:
Phone 1: ___________________________ Phone 2: _________________________ Phone 3: ________________________________
[INSERT CHAPTER NAME]
Rhosebud Health Information and Authorization Form
2
HEALTH INFORMATION (Check all that apply and provide requested information)
Allergies
Yes
No
Explain “yes” answers. Include the type of allergy (e.g.- “nut allergy” in the food category)
Animals
Insect Stings
Plants/Trees
Food
Drugs
Other
Explain any specific needs or accommodations required:
Explain any known behavioral and/or emotional problems:
Explain any disabilities or chronic or recurring illnesses:
Explain any activities that are discouraged or limited by your child’s physician:
Explain any dietary modifications:
Has menstruation begun? ☐Yes ☐No If yes, is her menstrual history normal? ☐Yes ☐No If not, does she know what it is? ☐Yes ☐No
Date of Last Health Exam: Current Height: Current Weight:
IMMUNIZATION HISTORY
Are all immunizations current? Yes No If not, state reason(s): DTP or DT (Tetanus) Date:
MEDICATION INFORMATION
Are any prescription medications being taken? Yes No Are any of the following used? Inhaler EpiPen
Name of Medication
Reason for Medication
Dosage
Frequency
My child may be given: Aspirin Benadryl Ibuprofen Neosporin Tylenol None
MEDICAL CARE AND INSURANCE INFORMATION
Physician: _________________ Phone:
Dentist/Orthodontist: Phone: _____________________________________________
Preferred Medical Facility: Address:
Insurance Company:
[INSERT CHAPTER NAME]
Rhosebud Health Information and Authorization Form
3
AUTHORIZATION FOR MEDICAL CARE
I, the undersigned, certify that the information provided on this form is accurate. The child listed above, has permission to
engage in all activities for the Rhosebud Club of [INSERT NAME OF CHAPTER] except as noted above. I hereby give
permission to the members [INSERT NAME OF CHAPTER] of Sigma Gamma Rho, Sorority, Inc. to provide routine health care
and witness prescribed medications. I consent for my child to receive such medical treatment and/or surgical procedures as
are deemed necessary in the event of an emergency and to assume liability for any medical expenses involved. This
authorization extends to my child’s participation in any activity sponsored by [INSERT NAME OF CHAPTER] of Sigma Gamma
Rho, Sorority, Inc. Should a medical emergency arise during my child’s participation in an activity sponsored by [INSERT
NAME OF CHAPTER] of Sigma Gamma Rho, Sorority, Inc., I understand that reasonable efforts will be made to contact me or
my designated emergency contact at the phone number(s) I have provided. If it is believed my child’s life or health may be
adversely affected by the delay that an attempt to contact me or my designated emergency contact would cause, I consent to
the administration of medical treatment and/or surgical procedure deemed necessary by the medical doctor and/or medical
facility and the immediate administration of life-sustaining measures deemed necessary under the circumstances. To ensure
prompt attention in the case of sickness or accident, I hereby authorize the persons in charge of the Rhosebud Club to incur
expenses necessary for treatment and I agree to pay for the same if this is in excess to the amount paid by any accident or
health insurance that may be in effect at the time of the sickness or accident. I authorize this form to be photocopied.
Parent/Guardian(s) Full Name (PRINTED): _____________________________________________________________________________
Parent Guardian’s Signature: _________________________________________________________ Date:_____________________
Rhosebud Advisor’s Name (PRINTED): _______________________________________________________________________________
Rhosebud Advisor’s Signature: _______________________________________________________ Date: ____________________
Chapter: ______________________________________ Region: _______________________________________
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

INSERT CHAPTER NAME Rhosebud Health Information and Authorization (Constant Contact)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document