Policy Number: ... Signature: Self or Parent/legal Guardian if under 18 years of age. Date. 2017. 2017. January 1 - Dece
2017 2017 Medical Form--Chapel Hill United Methodist Church
All Participants MUST have this Form Completed This form applies to ALL Youth Ministry related camps, trips, events, and/or outings for Jan. 2016-Dec. 2016 31, 2017 January 1 - December
Participant’s Name:___________________________________ Date of Birth:_____________________ Physical Problems or Limitations:_________________________________________________________ Name of Physician:_________________________________________ Phone #:___________________ Insurance Carrier Name:________________________________________________________________ Policy Number:______________________________________ Group #:__________________________ Parent or Legal Guardian Name:___________________________________________________________ Address:______________________________________________________________________________ Phone Numbers: Work________________ Home__________________ Cell_____________________ If Parent or Legal Guardian Cannot Be Reached, Contact: Name:____________________________________________ Phone Number:_____________________
Emergency Permission: In the event that __________________________________ suffers any illness or accident requiring emergency hospitalization, or surgery while participating in any activity of Chapel Hill United Methodist Church, I hereby give my permission for any necessary hospitalization, medication, or surgery on recommendation of a qualified physician after consulting the trip leader, understanding the leader and/or physician or nurse will contact me at the earliest possible moment. I also release from liability Chapel Hill United Methodist Church, its staff, and volunteers during an activity or event sponsored by Chapel Hill United Methodist Church. This authorization will remain in effect through December December 31, 31,2017 2016, unless revoked by me in writing. ____________________________________________________________ ________________________________ Signature: Self or Parent/legal Guardian if under 18 years of age Date
Medical History and Medication Participant’s Last Name:_____________________________ First Name:__________________________ Emergency Contact Name:____________________________ Cell #______________________________ Medication Allergies:____________________________________________________________________ Other Allergies (i.e. latex, bee stings, pollen, etc.)_____________________________________________ Medical History (i.e. diabetes, asthma, chronic illness):_________________________________________ Tetanus and Immunizations up to date? Yes / No Date of Last Tetanus:___________________________
Prescription Medications Medication Name (List Name as written on prescription bottle)
Time to be Taken (Breakfast, lunch, dinner, bedtime, etc.)
*Please note inhalers may be kept by Youth, but please list them above. May the participant have any of the following meds (if needed) for headache, cold symptoms or menstrual cramps? Please circle all that they may have: Tylenol Aspirin
Alleve Motrin
Tylenol Cold Benadryl
Alka Seltzer Excedrin
Pamprin Midol
Photo/Video Release: I hereby give my permission for images, captured during regular and special Youth activities through video, photo, and digital camera, to be used for the purposes of promotional material and publications, and waive any rights of compensation or ownership thereto. __________________________________________________________ Signature of Participant or Parent if Under 18 Years of Age
Date
