2023 Medical Information Form

Participant Information

Name

This address will receive a confirmation email

Phone

Address

Grade

Birthdate

Primary Emergency Contact

Emergency Contact Name

Emergency Contact Address (if different from above)

Emergency Contact Phone

Relationship

Alternate Emergency Contact

Alternate Contact Name

Alternate Contact Address (if different from above)

Alternate Contact Phone

Relationship

Insurance Information

Do you have hospital insurance?

Yes No

Insurance Company

Policy Number

Doctor's Name

Doctor's Office Phone

List pre-existing or current medical conditions:

List any allergies:

List any medical allergies:

If taking any medications, name and dosages:

Contact Lenses?

Yes No

Date of last Tetanus Shot:

Consent

I give permission for my child named above to participate in Faith Baptist Church youth group activities. While Faith Baptist Church youth leaders will take all appropriate safety precautions, I recognize that group type activities present inherent risks of injury and that by allowing my child to participate, I acknowledge and accept that risk and will not hold Faith Baptist Church liable. I further give permission for Faith Baptist Church youth leaders to authorize and obtain emergency medical care if needed and that I will be responsible for any and all medical costs associated with any injuries that arise from participation in youth group activities.

I agree to this statement

Yes

Parent Signature (type full name)

Today's Date

2023 Medical Information Form

Description

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