MIME-Version: 1.0 Content-Location: file:///C:/88F4CAAD/youthmedicalform.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" CHRIST THE SERVANT LUTHERAN CHURCH

CHRIST THE = SERVANT LUTHERAN CHURCH

MEDICAL INF= ORMATION FORM

 =

Youth’s Name:&n= bsp; ______________________     Parent or Legal Guardians Name: ___________________­­­­­­­­= ­­­­­­­­­­­­­­­= ­­­­­­­­­­­­­­­= ­­­­­­­­­­­­­­­= ­­­­­­_

 

Relationship:  ________________________  Address:  _________________________________________

 

Telephone Numbers, Home  _____________  Work #1  ______________ Work #2  __________________

 

Alternate contact Name:  _______________   = Phone #1 ______________  Phone #2 _________________

 

Special Needs:  _________________________________________  May the Youth swim?  Yes   No

 

Birth Date:  ______________&= nbsp; Diabetic  Yes   No     Last Tetanus Immunization:  _______________= ____

 

Allergies:_________________= ____________________________________________________________

 

Reactions:  ____________________________________________________________________= ________


Medical History (seizures, chronic illness, disorders, etc…):  __________________________________= __

___________________________= __________________________________________________________
___________________________________________________________________________= __________
___________________________________________________________________________= __________
___________________________________________________________________________= __________
___________________________________________________________________________= __________
___________________________________________________________________________= __________

 

Medications:  __________________________________= ________________________________________
___________________________________________________________________________= ___________

___________________________= ___________________________________________________________

___________________________= ___________________________________________________________

___________________________= ___________________________________________________________

___________________________= ___________________________________________________________

___________________________= ___________________________________________________________

___________________________= ___________________________________________________________

 

Physician:  ____________________________  Telephone No:  _________________________

 

Insurance Coverage:&n= bsp; ____________________________________________________________________=

 

Member No:  ______________________________  Employer:  __________________________________=

 

 

        =         Please note that the above information is confidential and will not = be released except in an emergency