The Lot Medical Form

Youth Information

Child's Name

Preferred Name / Nickname (if applicable)

Date of Birth

Parent / Guardian Information

Parent/Guardian Name

Relation to Youth

Parent/Guardian Phone

Allergies and Medical Needs

We want to make sure your young person can participate safely
and comfortably. Please share any information our adult leaders would need to know in an emergency or to support your young
person during activities.

1. Does your young person have any allergies we should know about?

Yes, Food Yes, Medication Yes, Other No

If yes, please explain:

2. Are there any medical conditions or health needs that could require attention during a gathering?

Yes No

If yes, please explain:

3. Does your young person need to have medication or emergency equipment available?

Yes, inhaler Yes, diabetes supplies Yes, Epi-pen Yes, other No

If yes, please explain:

4. Are there any accomodations that would help your young person participate comfortably?

Yes, accessibility needs Yes, sensory needs Yes, other No

If yes, please explain:

Emergency Contact Information

Primary Emergency Contact Name

Primary Emergency Contact Phone

Alternate Emergency Contact Name

Alternate Emergency Contact Phone

Emergency Medical Authorization

In the event of an emergency, The Lot Youth leaders will make
reasonable efforts to contact the parent/legal guardian identified
on this form.

If immediate attention is necessary, authorized leaders may
contact emergency medical services and provide relevant
information to responding medical professionals.

I understand that The Lot Youth leaders are not medical
professionals and that emergency medical decisions and
treatment will be handled by qualified medical personnel in
accordance with applicable law.

I confirm that the information provided is accurate to the best of
my knowledge and agree to notify The Lot Youth if my young
person's medical or emergency information changes.

Parent/Guardian Full Name (to serve as electronic signature)

Date

Your Young Person's Privacy Matters

The information used on this form will be used to support your person's safety and participation in The Lot Youth activities. Access will be limited to authorized individuals who need the information for their responsibilities, and relevant details may be shared with emergency responders when necessary.

Please contact us if any information needs to be updated.

The Lot Medical Form

Description

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