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This form is provided by Episcopal Diocese of New Jersey for the medical information release regarding the medical care and treatment necessary to be administered to the child.
Parent/Guardian Emergency Contact
Name(s)_________________________
Home Phone_____________________
Work Phone(s)____________________
____________________
Cell Phone(s) ____________________
__________________
MEDICAL RELEASE FORM – EPISCOPAL DIOCESE OF NEW JERSEY
Youth’s Name and Birthdate:___________________________________________________
The following is a list of medications that my child,
____________________________________, will need
to take while attending __________________________.
(Please attach a list if additional room is needed.) All
prescription medication must be properly labeled in its
original pharmacy container. Over the counter
medication must also have the youth’s name written