Youth Medical Consent & Permission Form

Youth Medical Consent & Permission Form
Student Name *

First Name Last Name
Birth Date *

Month Day Year
Gender *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Grade *
School attending *
Home Phone Number *

- Area Code Phone Number
Family email *
example@example.com
Father's Name

First Name Last Name
Mother's Name

First Name Last Name
Father's Cell Phone

- Area Code Phone Number
Mother's Cell Phone

- Area Code Phone Number
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number

- Area Code Phone Number
Relationship to Student
Insurance Information
Insurance Company *
Policy/Group Number *
Name of Insured *
Relationship to Student *
Doctor's Name *
Doctor's Phone Number *

- Area Code Phone Number
Hospital Preference
Special Health Information
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof.
Should this child's activities be restricted for any reason?
Allergies to: (please check all that apply)

Pollens Medications Food Insect Bites
List specific allergies:
Regular Medications taken: *
When and how often will medication need to be given:
Dietary Restrictions *
If the need should arise while at an event, my child may receive age/wt appropriate dose of: (please check all that apply) *

Acetaminophen (i.e. Tylenol) Cough Drops Ibuprofen (i.e. Motrin) Tums
Youth Medical & Media Release Agreement
As the parent or guardian of student listed above, by signing electronically, I agree to the Youth Medical and Media Release Agreement as state above *

Clear
Student Code of Conduct
I, the student, have read the above Student Code of Conduct, my Health Information, and permission to participate in youth group activities. I agree to abide by all stated personal limitations and code of conduct. *

Clear
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Youth Medical Consent & Permission Form

Insurance Information

Special Health Information

Youth Medical & Media Release Agreement

Student Code of Conduct