Gumc Medical Release Form printable pdf download

GUMC Medical Release Form

Please print in ink

Effective dates: September 1, 2012 to September 1, 2013

Name:

Age

Birthday

Last

First

Middle

Grade:

School:

___Male ___Female

Zip

Address:

City

State

Phone Home:

Email:

Medical Insurance Co.

Policy #

Mother’s Name:

Phone Work

Mobile

Father’s Name:

Phone Work

Mobile

Emergency Contact:

Phone

Mobile

Physician:

Office Phone:

Dentist:

Office Phone:

Medical History

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness,

propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the

Leaders of GUMC Youth Ministries and Pastors of Genesis UMC should be aware, and what, if any, action of

protection is required on account thereof. Submit this notification in writing and attach it to this form. Include

names of medications and dosages that must be taken.

Check the following areas of concern for this student. If necessary, add another page with details:

1. For your youth’s safety and our knowledge, is your student a –

___ good swimmer ___ fair swimmer

___ non-swimmer

2. Does your youth have allergies to pollens, medications, food, insects. If so, please explain:

_________________________________________________________________________________________

Does your youth carry an epipen? _____

Does your youth suffer from, has ever experienced, or is being treated currently for any of the following:

___ asthma

___ epilepsy/seizure disorder

___ heart trouble

___ diabetes

___ frequently upset stomach

___ physical disability ___ other

4. Does your youth take any medications regularly that we should be aware of?

_________________________________________________________________________________________

5. Date of last tetanus shot:

6. Does your youth wear

___ glasses

___ contact lenses

Gumc Medical Release Form

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