Devon Community Church: Authorization and Medical Consent Form
Information received is confidential and is being gathered for the purpose of serving your youth while in the care of Devon Community Church. Any medical information collected here serves to authorize Devon Community Church, and its staff and volunteers, to obtain medical assistance in emergencies.

Purpose and Extent: Devon Community church is collecting and retaining this personal information for the purpose of enrolling your youth in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your youth, and to inform you of program and upcoming opportunities at our church. This information will be maintained indefinitely as it is a requirement of our insurance company and legal council. If you wish Devon Community Church to limit the information collected, or to view your child's information, please contact us.
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For the year September 1, 2021 - August 31, 2022
Student #1 Name: *
Date of Birth Student #1: *
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Age (as of September 1, 2021) Student #1 *
Grade Student #1: *
Student #1: *
Health Card Number Student #1: *
Allergies Student #1: *
Student #1           Does your youth have any physical, emotional, mental, behavioral concerns or limitations that our staff should be aware of? *
Student #1  If yes, please explain:
Student #2 Name:
Date of Birth Student #2:
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Age (as of September 1, 2021) Student #2
Grade Student #2:
Student #2:
Clear selection
Health Card Number Student #2:
Allergies Student #2:
Student #2          Does your youth have any physical, emotional, mental, behavioral concerns or limitations that our staff should be aware of?
Clear selection
Student #2  If yes, please explain:
Student #3 Name:
Date of Birth Student #3:
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Age (as of September 1, 2021) Student #3
Grade Student #3:
Student #3:
Clear selection
Health Card Number Student #3:
Allergies Student #3:
Student #3           Does your youth have any physical, emotional, mental, behavioral concerns or limitations that our staff should be aware of?
Clear selection
Student #3  If yes, please explain:
Is your youth bringing any medications with him/her? Please be advised that Ministry Personals are not permitted to give or apply any medications. Please specify which student and which medications. *
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