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MEDICAL FORM (MUST BE FILLED OUT AND TURNED IN IF NOT ON FILE WITH CHURCH) ___________________________

PLEASE NOTE THE FOLLOWING:

Medical information only needs to be turned in once for the calendar year (January – December 2007).

If ANY “Medical Form” information changes a new “Medical Form” must be completed.

Please check and initial one of the following:

__________ Medical information has been turned into the NYI @ Warren First Church and is current. (Stop Here)

__________ This is the first time the NYI @ Warren First will receive Emergency Medical Information. (Continue Filling Out)

Please print legibly and complete all the parts of the form. All information contained herein will be treated confidentially.

DATE__________________________________

STUDENT NAME _______________________________________________________________________________________________________________

BIRTHDATE ___________________________________CURRENT GRADE LEVEL ___________________________________________________________

STREET ADDRESS______________________________________________________________________________________________________________

CITY __________________________________________ZIP_________________PHONE _____________________________________________________

CELL PHONE ________________________________EMAIL ____________________________________________________________________________

FATHER/GUARDIAN __________________________________________WORK PHONE _______________________________________________________

STREET ADDRESS (IF DIFFERENT THAN STUDENT’S) _________________________________________________________________________________

CITY ________________________________________________ZIP__________________ PHONE _____________________________________________

MOTHER/GUARDIAN________________________________________________________WORK PHONE_________________________________________

STREET ADDRESS (IF DIFFERENT THAN STUDENT’S)_________________________________________________________________________________

CITY________________________________________________ZIP______________________ PHONE __________________________________________

FATHER’S CELL PHONE_____________________________________MOTHER’S CELL PHONE________________________________________________

EMERGENCY CONTACTS (IF PARENTS’ CAN NOT BE REACHED)__________________________________________________

NAME_________________________________________________________RELATIONSHIP___________________ PHONE _________________________

NAME_________________________________________________________RELATIONSHIP___________________ PHONE_________________________

INSURANCE COMPANY_______________________________________________________________CLAIMS PHONE ______________________________

BILLING ADDRESS______________________________________________________________________________________________________________

GROUP NUMBER _____________________________________ POLICY/ID NUMBER ____________________________________

POLICY HOLDER’S NAME ________________________________________________________ RELATIONSHIP TO MINOR__________________________

STUDENT’S PHYSICIAN_________________________________________________________________ PHONE __________________________________

IS STUDENT CURRENTLY ON ANY MEDICATIONS? (CHECK ONE) YES________ NO________

MEDICATION ________________________________________________________ DOSAGE _______________________ PHONE ____________________

SPECIAL INSTRUCTIONS ________________________________________________________________________________________________________

MEDICATION ________________________________________________________ DOSAGE ______________________ PHONE_____________________

SPECIAL INSTRUCTIONS ________________________________________________________________________________________________________

DOES THIS STUDENT HAVE ANY ALLERGIES? (CHECK ONE) YES ________ NO ________ EXPLAIN BELOW:

_____________________________________________________________________________________________________________________________

ARE THESE ALLERGIES LIFE THREATENING? (CHECK ONE) YES _________ NO ________ EXPLAIN BELOW:

_____________________________________________________________________________________________________________________________

DOES THIS STUDENT HAVE ANY PHYSICAL, EMOTIONAL, MENTAL OR BEHAVIORAL CONCERNS OR LIMITATIONS THAT

OUR STAFF SHOULD BE AWARE OF? PLEASE EXPLAIN BELOW:

_____________________________________________________________________________________________________________________________

CONSENT FOR MEDICAL TREATMENT______________________________________________

I, _______________________________________________ the parent and/or legal guardian of

_________________________________________________ (said minor) born on________________________________________

allow said minor to participate in the above ‘said activity’ with the NYI @ Warren First Church of the Nazarene, including transpor-

tation if applicable, sponsored by Warren First Church of the Nazarene, a nonprofit corporation located at 4179 Parkman Road NW,

Warren, Ohio, 44481.

I recognize the possibility of physical injury associated with ‘said activity,’ and for Warren First Church of the Nazarene accepting

said minor to participate in ‘said activity,’ I hereby release, discharge, and/or other wise indemnify Warren First Church of the

Nazarene, its’ affiliated organizations, sponsors, employees, and associated personnel, against any and all claims by or on the

behalf of the minor as a result of the minor’s participation in the above referenced ‘said activity.’ This agreement and medical

authorization is good for the twelve month period and all copies are considered originals.

I do hereby authorize, consent and permit the rendering of general, necessary medical, dental, and/or surgical care or treatment

for the benefit of said minor as fully and with all intent and purposes as I would do if personally present.

______________________________

_________________________________________________________________________

Date

Parent or Legal Guardian

______________________________

_________________________________________________________________________

Date

Parent or Legal Guardian

______________________________

_________________________________________________________________________

Date

Witness