CSM Medical Form

Student's Name

Current grade of school

School Student Attends

Student's Cell Number (if they have one)

Student's Email (if they have one)

Birth Date

Student's Gender

Male Female

Address

Parent/Guardian's Name

Parent/Guardian's Phone

Parent/Guardian's Email

This address will receive a confirmation email

Emergency Contacts (other than listed above)

Insurance Company (if applicable)

Policy or ID Number (if applicable)

Family Physician

Family Physician Phone

Medications Currently Taking (if applicable)

Other Information

List Allergies (please include food sensitivities)

Date of Last Tetanus Shot

Permission to Give ibuprofen Acetaminophen Asprin

Special Instructions Regarding Student

Digital Signature of Parent

Date of Signature

Digital Signature of Student

Date of Signature

Description

By signing this form, I am stating that my child (named below) may participate in all Church Student Ministry events for the calendar year. As a parent or guardian, I authorize an adult counselor to make legal decisions, medical decisions, or otherwise concerning said minor during the time of Church Student Ministry events. I also agree that I will immediately notify Church Student Ministry, in writing, of any changes to the information below, medical or otherwise. I hereby release Calvary Baptist Church and its sponsors of any legal responsibilities and liability in the event of an accident or injury. As a parent or guardian, I have carefully and truthfully provided all the information requested and give my permission for my child to participate in Calvary Baptist Church Student Ministry events for this year. Both my child and I understand that he/she will be expected to obey the rules, regulations and policies of Calvary Baptist Church Student Ministry events.

CSM Medical Form

Description

Please Fix the Following