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Derry Presbyterian Church General Information & Medical Form for DPC Children & Youth Ministries
Please complete one form per child.
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* Indicates required question
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Grade
*
Your answer
Address
*
Your answer
City, State
*
Your answer
Zip Code
*
Your answer
School District and Name of School
*
Your answer
Church Activities Child is Involved With
*
Your answer
Non-Church Activities Child is Involved With
Your answer
Parent/Guardian Names
*
Your answer
Daytime Phone
*
Your answer
Cell Phone
*
Your answer
Parent's Email Address
*
Your answer
Medical Insurance Carrier
*
Your answer
Primary Physician
*
Your answer
Physician's Phone Number
*
Your answer
Medications Taken by Child
Your answer
Allergies
*
Yes
No
If your child has allergies, please explain in detail here.
Your answer
Does your child need any physical or intellectual accessibility accommodations?
*
Yes
No
Please explain any physical or intellectual accessibility needs.
Your answer
Other Important Medical Information
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
*
Your answer
By checking this box you are stating that all of the above information is up to date and accurate.
*
Yes it is.
Required
Date this Form is Completed
*
MM
/
DD
/
YYYY
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