Combination Form 22/23

Combination Form

To simplify the forms process, we have combined all yearly forms into this single, long form. This will include contact information, medical information, permission to treat, and the general permission slip. All information submitted through this form will be seen only by Eric or other leaders, and medical information is only for us to be aware of everyday medical needs and/or in the event of a medical emergency.
Student Information
Name *

First Name Last Name
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number *

Area Code Phone Number
Ok to text? *

Yes No
Date of Birth *

Month Day Year
Date

Emergency Contact Information
Primary Emergency Contact *

First Name Last Name
Relationship to Student *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number *

Area Code Phone Number
Ok to text? *

Yes No
Secondary Phone Number

Area Code Phone Number
Work Location *
Email *
example@example.com
Secondary Emergency Contact

First Name Last Name
Relationship to Student
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number

Area Code Phone Number
Ok to text? *

Yes No
Secondary Phone Number

Area Code Phone Number
Work Location *
Email *
example@example.com

Medical Information

In the event of an accident or special health need, it will be necessary for us to have the requested information. Please make certain that you have provided thorough and accurate information including scheduled times and dosages.
Prescription Medications
Please include dosages and times
Over the Counter Medications
Please include dosages and times
Do you have/have you had (check if Yes): *

Recent serious injury? Recent surgery? Chronic medical condition? Other health concerns? Nothing known
If YES to any of the above, please describe:
Tetanus current (last 10 years)? *

Yes No
Immunizations current? *

Yes No
Food allergies (please list)?
Medication allergies (please list)?

Medical Insurance Information
Name of Company *
Phone Number *

Area Code Phone Number
Policy Number *
Doctor Information
Family Doctor *
Office Phone *

Area Code Phone Number
After Hours Number

Area Code Phone Number

Permission to Treat

I understand that, in case of illness or injury, every possible effort will be made to contact me at the earliest possible time. However, if time does not permit, or if circumstances do not allow for this contact, I hereby give Sulphur Grove Church my permission:
- for first aid treatment to be given by church staff and/or volunteer leaders;
- to a licensed physician at a hospital emergency toom, office, or clinic to provide appropriate treatment as is deemed necessary for the physical wellbeing of my child;
- for my child to be transported and treated by a licensed rescue squad
Signature *

Clear

General Permission Slip

for all Grove Youth activities for the 2021-2022 school year
This is to certify that my student (named on page one of this form) has my permission to participate in youth and church related activities with Sulphur Grove Church. These activities may include meetings, lock-ins, events, and service projects both at the church and off-site. They may include transportation by youth leaders and other adults in their own vehicles or in a vehicle rented by the church. I understand that, in order to participate in any activity, my student must have a medical form on file, including permission for treatment in an emergency situation. I will be responsible for any necessary costs or fees for my student to participate in activities/outings.

I also understand that I will be made aware of youth activities in at least one of the following ways: the church newsletter, Sunday worship bulletins, information sheets, phone calls, e-mail, or social media.

I am aware that students not acting appropriately may be asked to leave an activity, and I may be responsible for picking them up and taking them home.

I understand that Sulphur Grove Church is not responsible for injury or illness due to inherent risks of teenagers having fun, though every safety measure and protocol to protect my and other students will be put in place.

I understand that pictures or video may be taken of my student, and possibly used in print or digital media. If I have any reason not to allow this, I have indicated so below.
For one reason or another, I would prefer my student's image NOT used in print or digital media
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
I understand that, as a youth group member, I am responsible for making sure that my parents/guardians are always aware of where I am and what I am doing when I attend youth group activities. I also understand that I am expected to behave appropriately to the situation and respond respectfully to those who are in leadership. I understand that my behavior and actions may limit me in the future from participating in youth events if they are inappropriate or harmful.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

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Combination Form

Student Information

Emergency Contact Information

Medical Information

Medical Insurance Information

Doctor Information

Permission to Treat

General Permission Slip