2019-2020 Youth Health & Waiver Form
If your child is attending any "extra curricular" church activity (other than Sunday or Wednesday night activities) throughout the year, we ask for you to fill out this health form and parental waiver. Everything is kept confidential and only referred to as needed.

**For Confirmation & Hi League youth attending off-site or overnight events: please respond to all required items, and as many other items as possible.

**For Sunday School youth: Please fill out all required items, but everything else is optional.
Email address *
Student Name *
Your answer
Student Birth Date
MM
/
DD
/
YYYY
Student Grade *
Your answer
Family Street Address
Your answer
Family Mailing Address, if different from street address
Your answer
Parent/Guardian 1 Name & Phone Number *
Your answer
What do they prefer? *
Parent/Guardian 2 Name & Phone Number *
Your answer
What do they prefer?
Other Emergency Contact Name, Relation & Phone Number
Your answer
List any food allergies we need to be aware of, along with preferred treatment: *
List any other allergies (environmental or medicinal) we need to be aware of, along with preferred treatment. *
Will your child need to take any medication while s/he is at a church-sponsored while you are not around? If so, please specify. Upon arrival please speak to the leader.
Does the student have any physical condition requiring special care, or any activity restrictions? Please explain. *
Medical Insurance Carrier
Your answer
I understand that, in a medical emergency, the adult chaperones will give every attempt to contact me. *
I give the adult chaperones to seek medical treatment for my child in case of illness or injury. *
Did we forget anything? Let us know here.
Your answer
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