CHURCH OF THE LAKES UNITED METHODIST
YOUTH FORM
Participant’s Name______________________________________________
Male/Female _______ Birth Date _______ Age _____
Parent/Guardian ________________________________________________
Street Address _________________________________________________
City ________________ State _____ Zip Code _______
Home Telephone __________________ Cell ______________________
Work Telephone _______________________
H E A L T H H I S T O R Y
Family Doctor __________________________ Number _________________________
Family Dentist __________________________ Number _______________________
ALLERGIC REACTIONS (Please list all known allergies - plant, insect, food, medicine AND TYPE OF REACTION):
________________________________________________________________________________________________________________________________________________
Please indicate any other medical problems/situations pertinent to your child:
________________________________________________________________________________________________________________________________________________
Any physical limitations? _____ If yes, explain ________________________________________________________________________
Any emotional/psychological limitations or reactions to be aware of? ____ If yes, explain:
________________________________________________________________________________________________________________________________________________
Is the student presently taking any medication?
________________________________________________________________________________________________________________________________________________
In an EMERGENCY, and if unable to reach parent/guardian, we should contact:
1. Name ______________________________ Number _________________________
2. Name ______________________________ Number _________________________
PERMISSION FOR ROUTINE MEDICAL TREATMENT
I grant permission for non-prescription medication (i.e., Tylenol, cough syrup, etc.) except for the following ___________________________ to be given to my student if deemed advisable by the designated supervisor of Church of the Lakes Untied Methodist.
PERMISSION FOR EMERGENCY MEDICAL TREATMENT
In case of emergency, I hereby give permission to transport my child to the nearest hospital/emergency center for emergency medical or surgical treatment to be decided by the Doctors and supervisors of Church of the Lakes United Methodist. I will be contacted as soon as possible.
*SIGNATURE _____________________________
*DATE ________________________
FAMILY INSURANCE PROVIDER/HEALTH PLAN ___________________________
HEALTH PLAN NUMBER ____________________________