STUDENT MEDICAL INFORMATION

The Student Ministry of Pleasant Dale Church

4505 W 300 N  Decatur, IN 46733  (260) 565-3797

 

The following information will be kept on file for up to four years.  After four years, this information will be discarded, and it will be necessary to fill out a new form for students who continue to participate in church-sponsored activities.  Please contact the Church office or Pastor Jonathan Crandall at 260-223-5812 with any questions you may have or important changes in medical information. 

 

 

DATE SUBMITTED: ___________________
 

STUDENT NAME: ____________________________________ CIRCLE:  MALE    FEMALE

 

BIRTHDATE: _____________PHONE: Home  _____________________Cell_____________________

 

ADDRESS: ___________________________________________________

CITY: ________________________________________ STATE: ____ ZIP:_____________


EMERGENCY CONTACTS:

NAME:_______________________________PHONE:_________________________________

NAME:_______________________________PHONE:_________________________________

 

NAME:_______________________________PHONE:_________________________________

 

HEALTH HISTORY (please explain any condition we should be aware of; use back of form if necessary):

Allergies (insect stings, drugs, food, etc.)_____________________________________________

Normal Treatment of allergic reactions: ____________________________________________________

Please explain any other conditions (heart, diabetes, asthma, epilepsy, etc.): _________________________

Medication(s) Currently Taking: ______________________________________Blood Type (if known): _______

INSURANCE
Your medical insurance carrier will be billed for medical charges in the case of illness or injury while participating in church-sponsored activities or while on the church premises.

Your Insurance Company: _______________________________ Policy Number: ___________________________

 

Other Helpful Insurance Information (specific contact information, etc.) _____________________________________