Form E - Mount Hermon Baptist Church Medical Release For Minors printable pdf download

Form E - Mount Hermon Baptist Church Medical Release For Minors

Mount Hermon Baptist Church

Medical Release Form for Minors

Today’s Date __________________

This form is valid for one year following today’s date.

Child’s Name __________________________________________________________

Address_______________________________________________________________

City/State/Zip __________________________________________________________

Date of Birth _____________________

SSN ____________________________

Parent/Guardian Name ___________________________________________________

Address (if different from above) ___________________________________________

City/State/Zip __________________________________________________________

Employer ______________________________________________________________

Daytime Phone ___________________

Evening Phone ___________________

Insurance Company ________________________ Policy No. ____________________

Name of Policy Holder ______________________ SSN _________________________

Are you currently taking medicine or treatment?

 Yes  No

If yes, explain _____________________________________________________

Have you been restricted from sports or swimming for any reason?  Yes  No

If yes, explain _____________________________________________________

Date of last Tetanus Toxoid Immunization: Month ____________ Year: _____________

Have you ever had a severe reaction to a bee/hornet sting or insect bite?  Yes  No

If yes, explain _____________________________________________________

Do you have:

List any Allergies:

 Sinus Trouble

Food ___________________________________________

 Hay Fever

________________________________________________

 Heart Trouble

Drugs ___________________________________________

 Epilepsy

________________________________________________

 Asthma

Other Medical Needs _______________________________

 Diabetes

________________________________________________

(Please continue on reverse)

Form D

Form E - Mount Hermon Baptist Church Medical Release For Minors