Youth Medical Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" background="abdfd5a3.jpg"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B> Grace Evangelical Church </B></FONT><B>    </B><B> |     </B><A HREF="index.htm" TARGET="_top" TITLE=" Grace Evangelical Church "><U><B>home</B></U></A></div> <div> <A HREF="id611.htm" TARGET="_top" TITLE="Background Check Form"><U>Background Check Form</U></A>   |   <A HREF="id612.htm" TARGET="_top" TITLE="Parental Consent Form"><U>Parental Consent Form</U></A>   |   <B>Youth Medical Form</B></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="b23d2b03.jpg"> <bR> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Youth Medical Form</I></div> <div>                                                                                              <FONT SIZE="4" COLOR="#000000" FACE="Arial" >Grace Evangelical Church</FONT></div> <div>                                                                                                   5905 E. Southport Road, Indpls, IN 46237</div> <div> <I>                                                                                                                       1-317-859-8008</I></div> <div>    </div> <bR> <div> <I>                                                          Medical Form 2012</I></div> <bR> <div> Name of child: _________________________________________   Date of birth:___________________</div> <bR> <div> Address:_____________________________________________________________________________</div> <bR> <div> Phone #: ________________________   Sex: _________   Height: _________   Weight: _____________</div> <bR> <div> <B><U>Insurance and doctor information:</U></B></div> <bR> <div> Do you have health insurance: ____________________________________________________________</div> <bR> <div> Name of insurance company: _____________________________________________________________</div> <bR> <div> Policy #: _________________________________   Group #: ___________________________________</div> <bR> <div> Name listed on policy: _____________________________   Insurance phone #: ____________________</div> <bR> <div> Doctor's name: _________________________   Phone #: ____________  City/State: ________________</div> <bR> <div> Dentist's name: _________________________   Phone #: ___________  City/State: ________________</div> <bR> <div> <B><U>Health Information:</U></B></div> <bR> <div> Please list current medications taken by minor and dosage: _____________________________________ </div> <bR> <div> ____________________________________________________________________________________</div> <bR> <div> Please list any known pre-existing conditions: _______________________________________________</div> <bR> <div> _____________________________________________________________________________________</div> <bR> <div> Please list all known allergies: ____________________________________________________________</div> <bR> <div> Date of last tetanus shot: ________________________________________________________________</div> <bR> <div> Does the child wear contact lenses: _____________________   Glasses: __________________________</div> <bR> <div> List any known restrictions or other special physical or dietary needs: ____________________________</div> <bR> <div> _____________________________________________________________________________________</div> <bR> <div> <B><U>Contact Information:</U></B></div> <bR> <div> Parent/guardian contact: ___________________________ Cell: __________________________</div> <bR> <div> Address: ______________________________________________________________________</div> <bR> <DIV ALIGN="LEFT"></DIV> <div> (continued on back)</div> <bR> <bR> <bR> <div> <B>(This form should be completed annually and a copy should be taken on each trip.)</B></div> <bR> <div> Being the parent or legal guardian of _____________________________ (minor's printed name), I ______________________________ (parent/guardian's printed name) do consent to any x-ray, anesthetic, medical, surgical, or dental diagnosis or treatment that may be deemed necessary for my minor child.  Further, I understand that all efforts will be made to contact me prior to treatment.  In the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment.  Should there be no activity leader available, I give permission to the attending physician to treat my minor child.  I further understand that the doctors, dentists, and other providers attending to my child will take all reasonable safety precautions during their care.  </div> <bR> <div> Further, as parent or legal guardian, I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the dental, medical, or hospital care or treatment that is given to my child.  Any policy of the church or organization sponsoring this event will be used as the secondary coverage.</div> <bR> <div> Minor's date of birth:  ___________________________________</div> <bR> <div> Parent/Guardian Signature:  ___________________________________     Date:  ______________</div> <bR> <bR> <div> Notarized by: _______________________________________________   Date: _______________</div> <bR> <div> Notary Seal/Stamp:</div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <A HREF="index.htm" TARGET="_top" TITLE=" Grace Evangelical Church "><U><B><IMG SRC="0c740400.gif" border=0 width="64" height="64" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="index.htm" TARGET="_top" TITLE=" Grace Evangelical Church "><U><B>Home</B></U></A></div> <bR> </td> </tr></table></body>