Health History And Emergency Medical Authorization Form - Archdiocesan Children'S Choir
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2Archdiocesan Children’s Choir
Health History and Emergency Medical Authorization Form
This form must be submitted annually by the child’s parent or guardian. If
Girl Health History and Emergency Medical Authorization Form
any changes occur in the information provided, the parent or guardian should
This form must be completed annually and as changes occur by the child’s
request a new form in order to provide updated information. Children will
parent or guardian and returned to the troop leader and/or troop first-aider
not be permitted to travel with the choir without a completed form on file.
prior to attending the first troop meeting. Use additional paper if needed.
Child’s Name:
Address:
City:
State:
Zip:
Date of Birth:
Age:
School:
Grade:
Number:
PARENT/GUARDIAN INFORMATION
Child is in the custodial care of:
Both Parents
Mother Only
Father Only
Other:
Parent/Guardian 1:
Address (if different than child’s):
Phone 1:
Phone 2:
Phone 3:
E-mail:
Parent/Guardian 2:
Address (if different than child’s):
Phone 1:
Phone 2:
Phone 3:
E-mail:
EMERGENCY CONTACTS
Name:
Relationship:
Phone 1:
Phone 2:
Phone 3:
Name:
Relationship:
Phone 1:
Phone 2:
Phone 3:
HEALTH INFORMATION (Check all that apply and provide requested information)
Allergies
Yes
No
Explain “yes” answers. Include the type of allergy (e.g.- “nut allergy” in the food category)
Animals
Insect Stings
Plants/Trees
Food
Drugs
Other
Condition
Dates
Condition
Dates
Condition
Dates
ADD/ADHD
Epilepsy
Muscle Disease/Disorder
Arthritis
Fainting
Nervous System Disorder
Asthma
German Measles
Sickle Cell Anemia
Athletes Foot
Hay Fever
Sinusitis
Bed Wetting
Headaches/Migraines
Skeletal Disease/Disorder
Bleeding/Clotting Disorder
Hearing
Skin Conditions
Bronchitis
Heart Defect/Disease
Sleep Disturbance/Walking
Chicken Pox
Hypertension
Stomach Upsets
Colds/Sore Throats
Kidney Disease
Urinary Tract Infections
Constipation
Measles
Wear:
Contacts
Glasses
Convulsions
Mononucleosis
Other:
Diabetes
Motion Sickness
Other:
Ear Infections
Mumps
Other:
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Parent category: Medical