___________________________ ____________________________ __________________________ ___________________
Last
Name First
Name Middle
Name Home
Phone
Male___Female___ Birthdate____/____/____ Age____ Member or Visitor of Timothy ________ Email_______________________
_______________________________ _____________________________________________________________ ___________________
Father/
Step Father Address Home
Phone
_______________________________ _____________________________________________________________ ___________________
Mother/
Step Mother Address Home
Phone
Father/
Step Father Cell Phone ________________________ Mother/ Step Mother Cell
Phone________________________
Emergency
and Health Information
Does the youth have… (If “YES” please explain)
____YES
____NO Allegies? _________________________________________________________________________________________
____YES
____NO Heart Condition? _________________________________________________________________________________________
____YES ____NO Other? _________________________________________________________________________________________
Is youth subject to….. (If “YES” please explain)
____YES
____NO Fainting? _________________________________________________________________________________________
____YES
____NO Sleep Walking? _________________________________________________________________________________________
____YES
____NO Upset Stomach? _________________________________________________________________________________________
____YES
____NO Motion Sickness? _________________________________________________________________________________________
____YES ____NO Other? _________________________________________________________________________________________
Does youth have a reaction
to…. (If “YES” please explain)
____YES
____NO Bee Sting? _________________________________________________________________________________________
____YES
____NO Penicillin? _________________________________________________________________________________________
____YES
____NO Poison Ivy/Oak? _________________________________________________________________________________________
____YES
____NO Other Drugs? _________________________________________________________________________________________
____YES ____NO Other? _________________________________________________________________________________________
Date of Last Tetanus Shot
________________
Please indicate ANYTHING
else which leader should know to help avoid or help with your youth’s health:
_____________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Insurance Information-
Please attach photo copy of insurance card
______________________________________ ________________________________________ ________________________________
Insurance
Company Insurance
Policy Number Name
of Policy Holder
Is pre-certification
required?____________ If “YES”, please indicate the
phone number ___________________
_______________________________________ _____________________ ________________________________________________________
Name
of Doctor Phone Address
You have my permission to
give my youth:
___YES___NO
cough medication ___YES___NO Dramamine If your youth is on medication, please specify type and
dose:
___YES___NO Acetominophen ___YES___NO Antacid
___YES___NO diphenhydramine ___YES___NO Ibuprofen ________________________________________________
___YES___NO topical cortisone ___YES___NO topical
anti-biotic
___YES___NO pepto bismal ___YES___NO solarcaine ________________________________________________
Emergency
Procedure: Leader will attempt to call Parent / Guardian / Doctor First
If
the leader is unable to contact you, please indicate your answer to the
following:
___YES___NO 1. With this signature I
hereby authorize First Aid by staff or youth workers and counselors.
___YES___NO 2. With this signature I
hereby authorize medical care by hospital staff and /or doctor selected by
church staff, youth workers or
counselors.
___YES___NO 3. With this signature I
hereby authorize doctor selected by church staff, youth workers or counselors
to hospitalize, secure medical
treatment for and to order
injection, anesthesia, blood transfusion, and/or surgery.
If
the parent/ guardian has answered “NO” to any of the above, parent /guardian
must indicate procedure to be followed in the event youth workers are unable to
contact parent / guardian:
_______________________________________________________________________________________________________________________
____________________________________________ ______________
Parent
/ Guardian Signature Date