Youth Medical Form

How many students are you filling this out for?*

1st Student

Student Name*

First Last

Student Phone Number

Date of Birth*

Grade*

Gender*

Fully Vaccinated for Covid-19?*

Yes
No
Prefer not to Answer

List All Allergies Below*

List All Medications Below*

2nd Student

2nd Student Name*

First Last

2nd Student Phone Number

Date of Birth*

Grade*

Gender*

Fully Vaccinated for Covid-19?*

Yes
No
Prefer not to Answer

List All Allergies Below*

List All Medications Below*

3rd Student

3rd Student Name*

First Last

3rd Student Phone Number

Date of Birth*

Grade*

Gender*

Fully Vaccinated for Covid-19?*

Yes
No
Prefer not to Answer

List All Allergies Below*

List All Medications Below*

4 or more Students?

Please List Students Name, Phone, Date of Birth, Grade and Gender.*

Please list information, separated by commas, with one student per line.

List All Allergies & Medications For Each Child. If They Do Not Have Any Allergies, Put "None"*

Parent/Guardian Information

Parent/Guardian Name*

First Last

Parent/Guardian Phone*

Parent/Guardian Email*

Parent/Guardian Name

First Last

Parent/Guardian Phone

Parent/Guardian Email

Additional Emergency Contact Name*

First Last

Additional Emergency Contact Phone Number*

Additional Emergency Contact Relationship to Student*

Insurance Information

Medical Insurance Company*

If none, please note N/A.

Insurance ID Number

Group or Policy Number

AUTHORIZATIONS

AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR AND RELEASE OF LIABILITY*

I hereby waive, release and covenant not to sue Pulaski Heights United Methodist Church and its officers, agents, employees, volunteers or activity chaperones from any and all negligence or fault which might proximately cause any claim, injury, death or liability resulting from my child’s participation in church sponsored activities.

I further give my permission for my child to be transported by church employees, volunteers or chaperones as part of his/her participation in this activity. I further hereby authorize and direct that the sponsors for this event be authorized to consent to medical treatment by qualified and licensed medical practitioners in the event of a medical or dental emergency, which, in the opinion of the attending physician, should be administered.

By checking this box I agree to the above statement

PERMISSION FOR PHOTOGRAPHING/VIDEOING YOUR CHILD*

From time to time we take pictures or record video during phyouth activities. We would like your permission to use these pictures on our website, our social media, in our newsletter. We will not reference your child by name or provide any specific information regarding your child. We also will never sell these pictures; we will use them exclusively for Pulaski Heights UMC purposes. Please take a moment to let us know your preferences regarding our use of photos of your children:

YES. I grant you permission to use photos/videos of my child on PHUMC's social media, website, bulletin boards, and /or newsletter.
NO. Please do NOT use any photos/videos of my child.

Type your full name as a signature.*

Photo of Insurance Card

Max. file size: 2 MB.

If able, please photo and attach image of your insurance card.

PHUMC Youth Medical Form

1st Student

2nd Student

3rd Student

4 or more Students?

Parent/Guardian Information

Insurance Information

AUTHORIZATIONS

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WHO CARES? WE DO!