2008-2009 NAAC Youth Ministry Health Form / Medical Release

Student Name: __________________________________ Date of Birth: ______________

Address: ___________________________________________________________________

Town: _______________________ State: _______ Zip: ________ Phone: ____________________

Gender: ______________________ Height: ______ Weight: _____ Social Security #: ____________

Emergency Contact Person

Name: ______________________________________ Relationship: _______________________________

Home Phone: _______________________________ Work Phone: _______________________________

Address if different from above: __________________________________________________________

Town: _______________________ State: ________ Zip: _________

Alternate Emergency Contact (If primary cannot be reached)

Name: ______________________________________ Relationship: _______________________________

Home Phone: ________________________________ Work Phone: _______________________________

Address if different from above: _________________________________________________________________

Town: ________________________ State: _________ Zip: __________

If you have medical insurance, your carrier may be billed for medical charges in the case of illness or injury while you child is at the activity. Do you have health insurance? ___ Yes ___ No

Name of Insurance Co: ______________________________________________________________________

Policy Number: _____________________________________ Group: ____________________________

Name policy is in: ___________________________________ Family Doctor: ______________________

Own Doctor: ______________________________________ Phone: _______________________________

If your child should require medical attention for injuries received or illnesses contracted prior to activity, please send us the necessary information to give him/her proper medical care during his/her time with the youth ministry activity.

Health History:

Current or preexisting conditions: _______________________________________________________________

Major illnesses during past year: ________________________________________________________________

Current medications: (include name and dosage) ___________________________________________________

Allergies: ___________________________________________________________________________________

Type of reaction and usual treatment for such a reaction: _____________________________________________

Date of last tetanus shot: _________________________________ Contact Lenses: _______________ Swimming Restrictions: ________________________________________________________________________

Activity Restrictions: __________________________________________________________________________

Parental Medical and liability release statement:

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 that 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/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 the North Avenue Alliance Church and it's 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 the North Avenue Alliance Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases or injuries incurred by the subject of this form.

Parent/Guardian Signature: ______________________________ Date: ________________________________

Signature of Student (if over 18 years): ____________________________________________________________

Please return this to

Pastor Steve to have on file

for this year’s youth activities.