We are attempting to have ONE health form for the whole

year to avoid filling out one for each trip.

HOPE MISSIONARY CHURCH Mandatory Health Form

FOR June 1, 2014 to May 31, 2015

Name of Student________________________________________Date of Birth________________SS # (opt.)______________________

Address________________________________________City_____________________State_________Zip_______________
Phone # ( )______________Gender______Height___________Weight_____________
Emergency Contact Person
Parent/Guardian Name_________________________________________Home Phone_________________Work______________
Address_____________________________________________City____________________State____________Zip____________
Alternate Contact Person
Name___________________________________Address__________________________________City______________________
Home Phone______________________Work Phone___________________________
If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your child is at the activity.
DO YOU HAVE MEDICAL INSURANCE? YES_________NO_________
Name of insurance company________________________________________________Policy No.__________________________
Group#__________________________In whose name is insurance?___________________________________________________
Family Doctor___________________________________City/Town________________________________Phone #_____________________
If your student should require medical attention for injuries received or illnesses contracted prior to activity, please send us the necessary
information to give him or her proper medical attention during his or her time with the youth ministry activity.
Health History Any pr e-existing or present medical conditions:_________________________________________________________________
_____________________________________________________________________________________________________________________
Name and dosage of any medications that must be taken:________________________________________________________________________
_____________________________________________________________________________________________________________________
Any allergies?_________________________To medications?______________________________________________________________
______Hay fever
______Heart condition ______Diabetes ______Asthma _____Insect stings ______Epilepsy/Nervous disorders
______Frequent stomach upsets
_____Physical handicap
______Any major illness during the past year?
If any of the above are checked, please give details (i.e. include normal treatment or allergies reactions)
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Date of last Tetanus shot________________________________Do you wear contact lenses?_________________________________
Any swimming restrictions?____________________________________If yes, what?__________________________________________________
Any activity restrictions?______________________________________If yes, what?__________________________________________________
PARENT PERMISSION AND MEDICAL LIABILITY RELEASE STATEMENT:
As parent/legal guardian of____________________________________________,I have reviewed the information about the youth activity and events
that he or she will participate in and give my permission for the subject of this release to be involved in the overall activities connected with Hope
Missionary Church and its youth ministry for the events between and including the days of June 1, 2014 to May 31, 2015. I have reviewed the rules of the
activities and agree that the subject of this release will abide by them. I also acknowledge that if the subject of this release has to return home for
discipline violations, it will be at my expense.
I consent to the use of any video images, photographs, audio recordings or any other visual or audio reproduction that may be taken of the subject of this
release during the activity/event to be used, distributed or shown as Hope Missionary Church sees fit.
I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form.
In the event I cannot be reached in an emergency during the activity dates shown on this form, I hereby give my permission to the physician or dentist
selected by the activity leader to hospitalize, to secure medical treatment, and/or order an injection, anesthesia, or surgery for my child as
deemed necessary.
I understand all reasonable safety precautions will be taken at all times by Hope Missionary Church and its agents during the events and
activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Hope Missionary
Church, its leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form and hereby
RELEASES them fr om liability for such damages, losses, diseases, and injur ies..

Parent/Guardian Signature____________________________________________________Date__________________________