Youth Info and Medical Form 2017-18
Youth's Name *
Your answer
Address: *
(Street, City, State, Zip)
Your answer
Youth's DOB: *
Your answer
Youth Email:
Your answer
Youth Cell Number:
Your answer
Youth t-shirt size (adult sizing): *
Grade in School: *
School: *
Your answer
Extracurricular Activities & Dates *
We would love to have any dates of games, plays, concerts, etc. in which you participate!
Your answer
Mother/Guardian's Name: *
Your answer
Mother/Guardian's Phone: *
Your answer
Mother/Guardian's Address (if different):
Your answer
Father/Guardian's Name: *
Your answer
Father/Guardian's Phone: *
Your answer
Father/Guardian's Address (if different):
Your answer
In the event that a parent/guardian cannot be reached, please contact the following relative(s)/friend(s) in case of an emergency: *
Your answer
Phone: *
Your answer
Insurance Company: *
Your answer
Group #: *
Your answer
Policy #: *
Your answer
Ins. Company's Address: *
Your answer
Ins. Company's Phone: *
Your answer
Cardholder Name: *
Your answer
Relationship to Cardholder: *
Your answer
Doctor's Name: *
Your answer
Doctor's Phone: *
Your answer
Special Health Conditions: (asthma, diabetes, allergies, etc.) and/or Special Instructions (allergic to certain meds, rare blood type, wears contact lenses, etc.)
Your answer
List Medications & Dose Information:
Your answer
MEDICAL RELEASE: We/I do hereby acknowledge that our son/daughter has permission to attend off-site functions sponsored by First Presbyterian Church, Hickory, NC; and I do hereby release the said church and the accompanying adult advisors from any legal liability or financial responsibility which may arise during the course of the function(s). I hereby authorize emergency treatment as deemed necessary in the event I cannot be contacted immediately. I realize that the health information described above will be kept in confidence. However, I give my permission for it to be shared with any adult in charge of a function on a need-to-know basis as determined by the youth leader. *
Signature of Parent/Guardian:
Your answer
Date: *
Your answer
MEDIA RELEASE: First Presbyterian Church (FPC), Hickory, NC has permission for the above named youth to be photographed with the understanding that the photograph may be in/on newspapers, Facebook, Instagram, FPC's website, and/or other media. *
Parent/Guardian Signature
Your answer
Date: *
Your answer
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