Youth Ministries Medical Form

Student Information
Name
First Last
Date of Birth
MM slash DD slash YYYY
Guest of:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Parent/Guardian Name 1
First Last
Phone
Parent/Guardian Name 2
First Last
Phone
Medical History
Family Doctor
Phone
History of Past/Present Illness
List Allergies
List Present Medications (dosage, frequency, times)
I give my son/daughter permission to receive over-the-counter remedies from the Varsity Staff
Insurance Information
Insurance Company
Policy Number
Consent
I give consent
I hereby grant permission to any qualified physician, to furnish such medical care as my son/daughter may require, including examination, treatment, immunization and so forth. This permission is conditioned upon the understanding that in the event of serious illness
or the need for hospitalization and/or surgery, the physicians will use all reasonable efforts to contact me. Failure in such efforts, however, should not prevent the physician for providing such emergency treatment as may be necessary for the best interest of my son or daughter.

62258

LOCATION:

999 Horseshoe Pike, Downingtown, PA 19335

610-269-8651