LC Students Medical Form
Thanks for filling this information out as accurately as possible! This will help us keep your student safe and allow us to get in direct contact with you during emergencies. Please answer 'none' if the information does not apply. Should you have any questions, please contact Zach Whitehead at zach@houmalife.com.
Student Info:
Student's full name: *
Your answer
Phone: *
Your answer
Birthday: *
MM
/
DD
/
YYYY
Gender: *
Street Address: *
Your answer
City, State, Zip: *
Your answer
Current Grade: *
Your answer
School: *
Your answer
Emergency Contact 1:
Full Name: *
Your answer
Relationship: *
Phone: *
Your answer
Emergency Contact 2:
Full Name: *
Your answer
Relationship: *
Phone: *
Your answer
Medical Information:
Insurance Company: *
Your answer
Policy #: *
Your answer
Insured ID or Member #: *
Your answer
Phone: *
Your answer
Physical limitations or special information: *
Your answer
Does your student take medications on a regular basis? *
If so, list them and frequency:
Your answer
Does a staff member have permission to distribute the medicine to your student? *
Consent:
Effective January 1, 2017 through December 31, 2017

As parent or legal guardian, I have given my child permission to take part in LC Students events, that is sponsored by Life Church as indicated by my signature.

In the event that he or she is injured while participating, I do hereby authorize and consent to any x-ray, examination, anesthetic, medical, or surgical diagnosis rendered under general or special supervision of any licensed medical staff member.

It is understood that this authorization is given in advance of any specific diagnosis or treatment being required but it may be given to provide authority and power to render care which the aforementioned physician, in his or her best judgement, may deem advisable.

It Is understood that effort shall be made to contact me, the undersigned, prior to rendering treatment to my child, but that any of the above mentioned treatment will not be withheld if I cannot be reached.

Electronic Signature: *
By typing your first and last name below, you are agreeing with the above terms.
Your answer
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