This form must be completed by the parent/guardian.
PARTICIPANT__________________________ BIRTHDATE____________ AGE____ SEX___
PARENT/GUARDIAN_________________________________ RELATIONSHIP____________
HOME ADDRESS_________________________________CITY_____________ZIP__________
HOME PHONE ________________________ WORK PHONE___________________________
IF NOT AVAILABLE FOR AN EMERGENCY, NOTIFY:
NAME____________________________ RELATIONSHIP___________PHONE____________
INSURANCE INFORMATION
INSURANCE COMPANY:__________________________ ID NUMBER__________________
INSURANCE ADDRESS:___________________________ CITY______________ ZIP_______
NAME OF POLICY HOLDER_______________________ Social Security _________________
_________________________________________________________________________________________
IMPORTANT: NO PARTICIPANT UNDER 18 YEARS OF AGE WILL BE ALLOWED TO PARTICIPATE UNLESS THIS BOX IS FULLY COMPLETED. AUTHORIZATION FOR MEDICAL TREATMENT
The undersigned parent/guardian/person authorizes the UMYM Director of the Prospect United Methodist Church to secure medical treatment for _______________________ in case of any illness or accident for which the UMYM Director or first aid personnel feels professional medical attention is required. I hereby give permission to the physician selected to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for me/my child as named.
_______________________________________________ __________________ ______________
Signature of Parent/Guardian or Participant if of legal age Relationship Date
I understand that the above signature authorizes the UMYM of Prospect United Methodist Church acting through its appointed Coordinator to secure medical treatment for me.
___________________________________________________________ _____________
UMYM Participant Signature Date
_________________________________________________________________________________________
Family Physician ____________________________________ Number _________________
HEALTH INFORMATION
Height _________ Weight__________ Allergies ____________________________________
Eyes- ( )Normal ( )Glasses ( )Contacts Ears *( )Normal( )Hearing Aid ( )Hard of Hearing
Medications (Please list all prescribed and over the counter)_______________________________
______________________________________________________________________________
Are you sending the medication_________________ Date of last Tetanus booster__________
Specific Medical History __________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Special Diet_____________________________________________________________________
(For Females)
Has this person menstruated?_____________ If not, has she been told about it?_______________
If so, is her menstrual history normal?___________ Special Considerations_________________
Adapted from the Illinois Great Rivers Conference The United Methodist Church Y.A.R. Health Form