Poplar Ridge Friends Meeting - Youth Medical FOrm

POPLAR RIDGE YOUTH MEDICAL FORM

This Medical Form can be used for all of our overnight trips this year. You still need to fill out a permission slip for each trip!

Youth's First Name

Youth's Last Name

Birthdate

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Youth's Cell Number (if applicable)

Parents or Guardians names & phone numbers. Please list at least 2 emergency contacts.

Medical Insurance Company

Insurance Company Phone Number

Policy Holder's First Name

Policy Holder's Last Name

Policy Number

Doctor's Name & Phone Number

Allergies or other health problems

Any Medications participant is currently using

In the event it becomes necessary to seek medical attention during the period he/she is a participant in this event, I, as parent or legal guardian, hereby authorize Tim Vestal (Youth & Family Pastor) or other leaders of the trip to execute proper medical treatment for the above participant.

I agree

Other

If Other, please explain