Senior Youth Medical Form 2024

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This Medical Form can be used for all of our trips in 2024.

You still need to fill out a permission slip for each trip!

Youth’s First & Last Name *

Date of Birth *

YYYY

Address *

Youth’s Cell Phone Number

Parents or legal guardians names and phone numbers. Please list at least 2 emergency contacts *

Medical Insurance Company *

Insurance Company Phone Number *

Policy Holder’s Name *

Policy Number *

Doctor's Name and Phone Number *

Allergies or other health problems *

Any Medications participant is currently using: *

In the event it becomes necessary to seek medical attention during the period he/she is a participant in this event, I, as parent or legal guardian, hereby authorize Tim Vestal (Youth & Family Pastor) or other leaders of the trip to execute proper medical treatment for the above participant. *

I agree

Other:

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