New Jersey Medical Release Form 1
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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
clearly on the container.
NAME OF MEDICATION

DOSE

Parent/Guardian Emergency Contact
Name(s)_________________________
Home Phone_____________________
Work Phone(s)____________________
____________________
Cell Phone(s) ____________________

__________________

WHEN TAKEN

___________________________________________________________________________________
___________________________________________________________________________________
Medical Conditions__________________________________________