Messiah LC Youth Ministry Medical Form for 2020
Please complete the information below if your child will be participating in any (or all!) activities/trips with MLC youth ministry! There will still be a separate (shorter!) permission form required for each off-site activity or trip.
NAME
Your answer
Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian Name & Home Address
Your answer
Parent/Guardian Preferred Email Address
Your answer
Phone Numbers (home, cells, other)
Your answer
Emergency Contact (in case parents cannot be reached) Include Name, Relationship and Phone number
Your answer
List any significant health problems
Your answer
List any medical exemptions (allergies, blood transfusion, etc.) for your child
Your answer
Are there any behavioral considerations or any other info that would be helpful to know while ministering/traveling with your child?
Your answer
My child is presently taking the following medications prescribed by a doctor
Your answer
Corrective Lenses?
Family Health and Accident Insurance Carrier
Your answer
Policy or Group Number
Your answer
Doctor's Name and Phone Number
Your answer
T-Shirt Size (Adult)
Submit
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