Health Form
Must be completed for every student participant
Email address *
Name of Student *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone # *
Your answer
Sex *
Emergency Contact Person
Parent/Guardian Name *
Your answer
Address (If different than above) *
Your answer
Primary phone # *
Your answer
Secondary phone #
Your answer
Alternate Contact Person
Use someone near the primary contact
Name *
Your answer
Primary Phone # *
Your answer
Secondary Phone # *
Your answer
Address *
Your answer
Insurance Info
If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your child is at the activity.
Do you have health insurance? *
Name of Insurance company *
Your answer
Policy # *
Your answer
Group #
Your answer
In whose name is the insurance? *
Your answer
Family Doctor *
Your answer
City *
Your answer
Phone # *
Your answer
If your child should require medical attention for injuries received or illness contracted prior to activity, please send us the necessary information to give him or her proper medical care during his or her time with the youth ministry activity.
List any pre-existing or present medical conditions: *
Your answer
List name and dosage of any medications that must be taken: *
Your answer
Any Allergies? *
Your answer
To Medications? *
Your answer
Hay Fever? *
Required
Heart condition? *
Required
Diabetes? *
Required
Insect Stings? *
Required
Epilepsy/Nervous? *
Required
Asthma Disorders? *
Required
Frequent upset stomach? *
Required
Physical handicap? *
Required
Any major illness during the past year? *
Required
If any of the above is checked "yes", please give details:
Your answer
Date of last Tetanus shot *
MM
/
DD
/
YYYY
Contact lenses? *
Required
Any Swimming restrictions? *
Required
Any activity restrictions? *
Required
By typing your name below, you agree that all the information provided is correct and hereby agree to the Liability Release Statement
Parent/Guardian Signature: *
Your answer
Signature of Student (If over 18 years old):
Your answer
A copy of your responses will be emailed to the address you provided.
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