Calvary Chapel Summerviille

EpiPen/Inhaler/Medical VBS Consent Form

The safety and well-being of your child is the top priority at Calvary Chapel Summerville. To ensure we can provide the appropriate care in case of an emergency, please complete this consent form for your child to carry and/or use an EpiPen or inhaler during Vacation Bible School (VBS).

Child's First Name

Child's Last Name

Child's Date of Birth

Allergy/Condition requiring EpiPen or inhaler

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone Number

Secondary Contact First Name

Secondary Contact Last Name

Secondary Contact Phone Number

Medical Information

Type of Medication

Please indicate which item your child is authorized to carry

EpiPen

Inhaler

Other Medication (Provide information below)

Type of Medication

Dosage Instructions

When to Administer (specific symptoms or triggers)

Additional Instructions (if any)

Consent and Acknowledgement

I understand that VBS staff and volunteers will take all reasonable precautions to ensure the safety of my child, but release Calvary Chapel Summerville from any liability related to the administration of the medication.

Thank you ensuring we have the necessary information to keep your child safe during VBS. If you have any questions or specific concerns, please contact Joanna Zantow at 732-6754938.

By signing below, I grant permission for my child to:

Carry their EpiPen/Inhaler during VBS
Self-Administer the medication if needed (if age-appropriate and trained)
Have the medication administered by trained VBS staff or volunteers if my child is unable to self-administer

Parent/Guardian Signature

EpiPen/Inhaler/Medical VBS Consent Form

Medical Information

Consent and Acknowledgement

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