Youth Ministries Medical Form

We'll get back to you right away!

Thank You! Your message successfully sent!
Failed! Please complete all mandatory (*) fields!
Student Information
 

Contact Information

Medical History
Characters Left
Characters Left
Characters Left

Insurance Information

I hereby grant permission to any qualified physician, to furnish such medical care as my
son/daughter may require, including examination, treatment, immunization and so forth.
This permission is conditioned upon the understanding that in the event of serious illness
or the need for hospitalization and/or surgery, the physicians will use all reasonable
efforts to contact me. Failure in such efforts, however, should not prevent the physician
for providing such emergency treatment as may be necessary for the best interest
of my son or daughter.

This authorization must be approved by a parent ofr guardian if student is under 18 years old.