Health Form


Name of Student _________________________________________________ Date of Birth _____________ Age ______ Address ______________________________________________________ City _____________ State _____ Zip ________ Phone # ______________ Sex ____ Height _________Weight __________ Social Security # ___________________________


Emergency Contact Person: Parent/Guardian Name __________________________________________ Phone # ______________ Work # ______________


Address (if different from above) _______________________________________ City ____________ State _____ Zip ________


Alternate Contact Person: (Use someone near the primary contact) _______________________________________________ Phone # ______________ Work # ______________ Address: ____________________________________________________________________


If you have medical insurance, your carrier will be billed for the medical charges in the case of illness or injury while your child is at the activity. Do you have health insurance? _____Yes


_____ No


Name of Insurance Company ________________________________________________________________ City _______________________________ Family Doctor ____________________________________________________ Policy #_________________________________________


Group #___________________________________________ In whose name is the insurance?___________________________________________ Phone #_______________________


If your child should require medical attention for injuries received or illnesses contracted prior to activities, please send us the necessary information to give him/her proper medical care during his/her time with the youth ministry activity.


Health History: Pre-existing or present medical conditions _____________________________________________________________________


Name and dosage of any medications that must be taken __________________________________________________________ _____________________________________________________ Any allergies? _____________ to medications?____________


__ Hay Fever __ Insect Stings __ Asthma __ Heart Condition __ Diabetes __ Epilepsy/Nervous Disorders __ Frequent Stomach Upsets __ Physical Handicaps __ Any major illness during the past year? If any of the above are checked, please give details (i.e., include normal treatments of allergic reactions)


Date of Last Tetanus Shot _________________ Contact Lenses? _____ Any swimming restrictions? ____ Yes ____ No


What? __________________________________________________________________________________________________ Any Activity restrictions? ____ Yes ____ No What? __________________________________________________________________________________________________


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