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STUDENT Medical Form 2020 - RPC Student Ministry
Form needs to be filled out once in 2019.
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* Indicates required question
Student Last Name:
*
Your answer
Student First Name:
*
Your answer
Gender
*
Male
Female
Graduation Year
*
Class of 2027
Class of 2026
Class of 2025
Class of 2024
Class of 2023
Class of 2022
Class of 2021
Class of 2020
Adult
Student - Phone
Your answer
Student Birthdate:
*
MM
/
DD
/
YYYY
Parent/Guardian 1 - Name
*
Your answer
Parent/Guardian 1 - Email
*
Your answer
Parent/Guardian 1 - Phone
*
Your answer
Address, City, State Zip (address of student and parent/guardian 1)
*
Your answer
Parent/Guardian 2 - Name
Your answer
Parent/Guardian 2 - Email
Your answer
Parent/Guardian 2 - Phone
Your answer
Medical Information
Medical Insurance Carrier
Your answer
Policy or Group #
Your answer
Carrier Address
Your answer
Family Physician - Name
Your answer
Family Physician - Phone
Your answer
Dentist/Orthodontist - Name
Your answer
Dentist/Orthodontist - Phone
Your answer
Health History
Check all that apply & provide explanation/dates (below)
Frequent Ear Infections
Diabetes
Bleeding Disorders
Hay Fever
Heart Defect/Disease
Asthma
Mononucleosis
Poison Ivy
Seizures
ADHD
Down Syndrome
Penicillin
Chicken Pox
Measles
Mumps
Insect Stings
Provide dates/explaination of any items checked above
Your answer
Chronic or Recurring Illness/Medical Condition
Your answer
Dietary Restrictions
Your answer
Blood Type (if known)
0+
0-
A+
A-
B+
B-
AB+
AB-
Clear selection
All immunizations (MMR, Tetanus, Hepatitis) current?
yes
no
Clear selection
Describe student's swimming ability?
can't swim
beginner
intermediate
advanced
Clear selection
Medication
Please bring student's medication that is needed to check-in. Leaders will distribute medicine based on dosages and time. We will bring a medical first aid kit with basic medication.
Medication 1 - Name
Your answer
Medication 1 - Dosage
Your answer
Medication 1 - Reason for taking
Your answer
Medication 2 - Name
Your answer
Medication 2 - Dosage
Your answer
Medication 2 - Reason for taking
Your answer
Medication 3 - Name
Your answer
Medication 3 - Dosage
Your answer
Medication 3 - Reason for taking
Your answer
Is there any other information you feel the leaders should know in advance about your student?
Your answer
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