Medical Consent Form

Youth Medical Consent Form

Youth Name*

Gender

Birthdate*

Age

-- Parent or Guardian Information --

Parent or Guardian Name

Home Address

Home Phone( ) -

Cell Phone( ) -

-- If not available in emergency notify --

Emergency Contact Name 1:

Emergency Phone 1:( ) -

Emergency Address 1:

Emergency Contact Name 2:

Emergency Phone 2:( ) -

Emergency Address 2:

-- Allergies and Doctor Information --

Other Allergies:

Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child's participation in this Activity?

If yes, describe the problems or illness:

State the name, address, medical specialty, and phone number of this child's family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name, address and phone number of this child's dentist (and orthodontist, if applicable):

-- Insurance Information --

Is there medical or hospitalization insurance which provides benefits for this child?

If so, please indicate: Name of insurance Company

Insurance Company Address:

Phone Number of Insurance Co.:( ) -

Policy No. of Insurance Policy:

Name of Policy Holder:

-- Restrictions and Medications --

Indicate the date of this child's last tetanus shot:

Are there any activities, such as strenuous activities, to be restricted for this child?

If so, describe:

Is this child on any medications?

If so, please state the medication:

Will this child be bringing the medication that s/he should be taking to the activity?

Describe any dietary restrictions that this child is required to observe:

Other comments or suggestions from the parent or guardian concerning this child:

I understand that FCUMC Youth Ministry carries medical and hospitalization insurance coverage which, consistent with the exclusions, limitations, and terms thereof, may provide benefits over and above any personal medical and hospitalization coverages available to my family. I understand that any personal medical and hospitalization insurance available to my family will provide primary coverage and the ministry's medical and hospital coverage (subject to the exclusions, limitations and provisions in the ministry's policy) may provide secondary or excess coverage. I agree to apply first for benefits from the personal hospitalization and medical coverage available to my family, if any, before applying for benefits that may be available from the ministry's medical and hospitalization coverage.

I further understand that, in the event my child requires medical or dental treatment while engaged in the Activity, reasonable efforts will be made to contact me; however, if I cannot be reached, I hereby consent and give permission to the ministry's sponsor or any adult counselor acting on behalf of the ministry with respect to the Activity, as agent for me, to consent to any X -ray examination; examination; injections; anesthesia; medial, dental, or surgical diagnosis and treatment; and hospital care and treatment advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my child’s medical allergies, medications being taken, medical problems, and other pertinent information. My child has permission to participate in all prescribed activities except as noted by me.

Parent Name:*

Parent Email:*

Today's Date:*

Please leave this field blank.