Microsoft word - youthmedform

Medical Information Form
For Participation in All Youth Activities of Fairmount Avenue United Methodist Church
Student Information
Name_____________________________________________________________________________________ Home Address_____________________________________City______________State_____Zip___________ Home Phone ______________________________________Date of Birth______________________________ Emergency Contact Information
Parent/Guardian Name
Home address (if different)______________________City_________________State_______Zip___________ Phone #: Day (____)__________________ Eve (____)_________________ Cell (____)________________ Work Name _______________________________________ Phone Number____________________________ Parent/Guardian Name_____________________________________________________________________
Home address (if different)______________________City_________________State_______Zip___________ Phone #: Day (____)__________________ Eve (____)_________________ Cell (____)________________ Work Name _______________________________________ Phone Number____________________________ Alternate Contact__________________________________________________________________________
Phone #: Day (____)__________________ Eve (____)_________________ Cell (____)________________ Health Care Provider
Physician Name/Clinic ______________________________________________________________________ Address __________________________________________________________ Phone #_________________ Dentist/Orthodontist Name/Clinic______________________________________________________________ Address __________________________________________________________ Phone #_________________ Preferred Hospital __________________________________________________________________________ If under the care of a medical specialist, please provide: ____________________________________________ Address___________________________________________________________ Phone #_________________ Insurance Information ***Attach copy of insurance card (both sides)***
Policyholder’s name_________________________________________________________________________ Name of Insurance__________________________________________________________________________ Phone Number____________________________ Policy/Group #_____________________________________ Health History
Allergies (please list ALL known allergies, including food, medication, insect, substances, latex, seasonal, etc.)
_________________________________________________________________________________________ Describe the reaction and what is done to manage it: _____________________________________________ _________________________________________________________________________________________
Diet (please indicate any that apply)
Other ________________________________________________________________________________
Routine Health Care:
My child is allowed to take / use over-the-counter medications under the supervision of an adult leader, such as: Acetaminophen (ex: Tylenol), Ibuprofen (ex: Advil), Benadryl, Pepto Bismal, Antacids, Antibiotic Ointment List any over-the-counter medication NOT to be administered _____________________________________
Medication If your child takes medication routinely, please fill out the below.

Name of Medication: __________________________ Name of Medication: ________________________ Reason for taking: ____________________________ Reason for taking: ___________________________ Dose taken: _________________________________ Dose taken: ________________________________ Time(s) of day: ______________________________ Time(s) of day: _____________________________ Please have an adult administer all routine medications listed above Health Concerns: Check all that apply to your child. Please provide instructions on how to manage this concern.
Other ____________________________________________________________________________________ List information on how this health care need can be supported. _____________________________________ _________________________________________________________________________________________ Other Special Health Problems or Concerns _____________________________________________________ _________________________________________________________________________________________ Tetanus Booster: Date of last shot_______________________________________
Permission and Emergency Release
I grant permission for _____________________ to participate in all FAUMC activities and overnights for the 2012-2013 school year. I assure that my child is in good health. In consideration of my child’s participation, I agree to indemnify the church and Minnesota Annual Conference of the United Methodist Church against any claim of any kind that arises out of any behavior or actions by my child at these events. I understand that in case of an emergency, every attempt will be made to contact me as a parent/guardian. In case I cannot be reached and care is needed immediately, I give permission for the youth leaders to take my child to a hospital for appropriate treatment. I hereby authorize the administration of medications or treatment deemed necessary by the chaperones for the health and welfare of my child. ________________________________________________ Signature of Parent/Guardian


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