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Salt Pump Portsmouth Medical Form

This form is to be completed by a parent/legal guardian. Any medications to be administered during program hours will be held in care of out staff. Medications will be self-administered by the child themselves under the supervision of our program staff. 

Please select who will be participating...
AdultMinor
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First Parent or Primary Contact Name
First Name*
Middle Name
Last Name*
Phone*
First Parent's Age Acknowledgment*
First Parent's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Parent Signature*
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact Information
Primary Contact Name *
Primary Contact Phone Number *
Secondary Contact Name *
Secondary Contact Number *
Insurance Information
Insurance Company *
Name of Insured *
Policy Number *
Primary Care Doctor *
Primary Care Doctor's Number *
Allergy Information
Does your child have any food allergies? *
No
Yes
If yes, please list below.
Does your child have any medication allergies? *
No
Yes
If yes, please list below.
Emergency Medications (inhaler, epi-pen, etc.) *
Does your child have any additional allergies we should be aware of?
Medications
Does your child take any medications daily? If so please complete the information below. *
No
Yes
Medication 1
Time of Administration
Reason for Medication
Potential Side Effects
Medication 2
Time of Administration
Reason for Medication
Potential Side Effects
Any additional medications
Other concerns or limitations
Are there any additional concerns or limitations you would like Salt Pump to be aware of?
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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