Child Information/Permission Form 2019
This form must be turned in at the time of registration for AIM
This form must be completely filled out individually for each child. Parents must sign.
Sign in to Google
to save your progress.
Child Name: Date of Birth: Age:
Phone Number (Home): Cell Phone:
Work Number (Parent or Guardian)
Chaperone/Youth Leader Name
Chaperone/Youth Leader Phone Number (Home or Cell):
Chaperone/Youth Leader email address:
In case of emergency notify:
Please Check all that apply to your child.
High Blood Pressure
Asthma (Is child on inhaler or medication?)
Sickle Cell Anemia
Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Disorder (ADD)
Wear hearing devices
Other medical problems not listed
Please list all medications child is currenlty receiving:
Has child ever been hospitalized or had any allergies? If so, please explain.
Child's physician: Phone#:
Medical Insurance Company: Policy#:
Parent/Gurdian Electronic Signature:
Parents please included your birthdate.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service