Messiah LC Youth Ministry Medical Form for 2021
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
Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian Name & Home Address
Parent/Guardian Preferred Email Address
Phone Numbers (home, cells, other)
Emergency Contact (in case parents cannot be reached) Include Name, Relationship and Phone number
List any significant health problems
List any medical exemptions (allergies, blood transfusion, etc.) for your child
Are there any behavioral considerations or any other info that would be helpful to know while ministering/traveling with your child?
My child is presently taking the following medications prescribed by a doctor
Corrective Lenses?
Family Health and Accident Insurance Carrier
Policy or Group Number
Doctor's Name and Phone Number
T-Shirt Size (Adult)
Clear selection
Submit
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