Adult Med Form

Adult Medical Form

Houston Northeast - Student Ministry
MS Email
Name
Date of Birth

MonthDayYear
Age Now
Biological Sex

malefemale
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number

Area CodePhone Number
Phone Number 2 (optional)

Area CodePhone Number
Email (optional)
A copy of this form will be sent to email provided.
EMERGENCY CONTACT 1
Emergency Contact 1 Name
Phone Number

Area CodePhone Number
Relationship
i.e., spouse, parent
EMERGENCY CONTACT 2
Emergency Contact 2 Name
Phone Number

Area CodePhone Number
Relationship
i.e., spouse, parent
MEDICAL CARE
List all allergies (food, drugs, insects, etc.)
Are you currently taking any medication?

yesno
If so, what medication? For what? How often?
Please provide any additional important medical or other information, which you feel may help Houston Northeast care for you more effectively.
MEDICAL INSURANCE
Insurance Company
Group #
Policy #
Phone # of Insurance Company

Area CodePhone Number
MEDICAL AUTHORIZATION

In the event of a change in my medical condition, I will notify Houston Northeast Church in writing. I understand that I can revoke this medical authorization at any time upon notice in writing to Houston Northeast Church.

I hereby give permission to Houston Northeast Church and the physician selected by Houston Northeast Church representative to secure medical treatment that may be deemed necessary to ensure my well-being. I, the undersigned, do hereby release Houston Northeast Church from any and all claims, demands, actions or cause of action arising out of damage or injury while participating in Houston Northeast Church sponsored activities.
Signature Authorizing Medical Care - use mouse (computer) or finger (touch-screen devices) to sign*
Should be Empty:

Adult Medical Form