Health Information for the
This must be completely (filled In and signed) by a parent or guardian in order for you to attend any of the Youth Ministries Events.
Youth Name:____________________________________________________________ Date of Birth: _____________________
Address: ________________________________________________________________ Home Phone: ______________________
Cell Phone: ____________________________________________ Eddress: ___________________________________________
Persons to contact in case of an emergency: (Two people available during the events)
Phone:______________________________________________ Cell Phone ______________________________________
Phone:______________________________________________ Cell Phone ______________________________________
Allergies:________________________________________________________________________________________________
Current medications and dosage: ____________________________________________________________________________
Conditions requiring special attention: ______________________________________________________________________
Doctor's Name: ______________________________________________ Phone: __________________________________
Health Insurance Provider: _______________________________________________ policy #: _________________________
As parent or legal guardian of: ____________________________________________________________________________
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I certify that the above information is complete and correct. I further authorize the adult leaders of this event to secure emergency
medical care, including hospitalization and other medical attention deemed necessary by a licensed physician or an emergency medical
service, for my child, until I can be contacted. I further acknowledge that all costs associated with any medical treatment for illness or
accidents while at the event are my responsibility.
Parent or Guardian signature ______________________________________________________ Date _____________________