Microsoft word - medicalinfo2010

I would like to keep this information on file to use for future Northfield Community Church events.
❐ Yes, keep my information on file for future 2010 events. (Info will be kept for 1 year from submission.)
❐ No, I will resubmit information for future events. BASIC INFORMATION
Participant Last Name: ________________________________________ First Name: _____________________ Participant Birth date _____/______/______ Grade completed in Spring of 2011: __ __ Youth Mobile Phone: __ __ __-__ __ __-__ __ __ __ __ __ Parent Email: ________________@_____________ Home Address: ___________________________________ City _____________ State__ __ Zip __ __ __ __ ___ Home Phone: __ __ __-__ __ __-__ __ __ __ __ Father Name: _____________________________ Father Contact Phone: __ __ __-__ __ __-__ __ __ __ ___ Mother Name: ____________________________ Mother Contact Phone: __ __ __-__ __ __-__ __ __ __ ___ EMERGENCY CONTACT INFORMATION
Emergency Contact 1: ___________________ Phone: __ __ __-__ __ __-__ __ __ Relationship: ____________ Emergency Contact 2: ___________________ Phone: __ __ __-__ __ __-__ __ __ Relationship: ____________ Emergency Contact 3: ___________________ Phone: __ __ __-__ __ __-__ __ __ Relationship: ____________ MEDICAL INFORMATION
A NCC Team Leader may administer the following checked OTC medication to the participant, if needed:
❐ Tylenol
Name of Physician/Practice: __________________________________________________________________ Office location: _____________________ Physician’s Office/On-call Phone: __ __ __-__ __ __-__ __ __ __ ___ Teen suffers from the following (check all that apply):
❐ Diabetes
Please explain checked item(s): ____________________________________________________________________ __________________________________________________________________________________________ MEDICATION: This information will be kept confidential. It is important that all medications are listed. Please
specify any prescription medication(s) being taken and the dosage: ___________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ALLERGIES Check all that apply. Describe reaction and treatment.
❐ Aspirin: _________________________________________________________________________________ ❐ Penicillin: ________________________________________________________________________________ ❐ Sulfa: ___________________________________________________________________________________ ❐ Insect Stings: _____________________________________________________________________________ ❐ Medication: ______________________________________________________________________________ ❐ Food Allergies: ___________________________________________________________________________ INSURANCE INFORMATION
A copy of participant’s insurance card is attached. Carrier Name: ______________________________________________________________________________ Name of Insurance Policy Holder: ______________________________________________________________ Policy #: ______________________________________ Group ID: ____________________________________ PERMISSION FOR EMERGENCY TREATMENT
Since minors may not, as a rule, be administered medical treatment without the written consent of a parent or guardian, parents or guardians are asked to sign the following statement. This may help to prevent a dangerous delay in case a medical emergency arises whereby medical treatment during the trip, including transportation, is necessary. In the event of illness or injury to ___________________________________ I hereby authorize any of the NCC Adult Team Leaders who accompany my son/daughter on this trip to obtain such medical treatment as any such person deems necessary under the circumstances and, where required, to give consent for such medical treatment as may be necessary to the same extent and with the same effect as though I had given it myself. ______________________________________________________ __ __/__ __/__ __ Signature of Parent/Guardian ______________________________________________________ Printed Name of Parent/Guardian FOR OFFICE USE ONLY
Received By: _____________________________________ Missing Item(s): _______________________________________________________________________ Missing Items Completed: __ __/__ __/__ __ Received By: ____________________________________________________

Source: http://nccyouth.net/uploads/medicalform.pdf