Health History Form

Name: *

First

Last

Choose One: *

Male Female

Date of Birth: *

Student Email: *

Mailing Address: *

Line 1

Line 2

City

State

Zip Code

Country

School: *

Grade: *

Student Home Phone: *

Student Cell Phone: *

Student Cell Carrier: *

Can receive text message reminders about upcoming events, deadlines, and schedule changes *

Yes No

Parent/Guardian 1

Parent 1 Name: *

First

Last

Parent 1 Relationship: *

Parent 1 Cell Phone: *

Parent 1 Email: *

Parent 1 Home Phone: *

Parent/Guardian 2

Parent 2 Name: *

First

Last

Parent 2 Relationship: *

Parent 2 Cell Phone: *

Parent 2 Email: *

Parent 2 Home Phone: *

in case of emergency

Emergency Contact (Not Parent/Guardian 1 or 2): *

First

Last

Emerg. Relationship: *

Emerg. Phone Number: *

Student health

List all medications: *

Additional Comments: *

Parent / Guardian E-Signature (Full name & DOB): *

Student will be responsible for own medication: *

Yes No

Student may be given Tylenol/ibuprofen for headaches and/or minor injuries: *

Yes No

This health history is correct as far as I understand, and the person herein described, is free of potential health problems which might restrict his or her participation (except as noted). In the event I cannot be reached in an emergency, I hereby give permission to the physician, hospital, clinic selected by the youth leaders to treat, hospitalize, secure proper anesthesia, injections or surgery.

Health History Downloadable Form
File Size:	383 kb
File Type:	pdf

Student Information

Parent/Guardian 1

Parent/Guardian 2

in case of emergency

Student health