Youth Conference STUDENT MEDICAL FORM

Distance Education Student Medical Form
STUDENT INFORMATION:
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Age:
Date of Birth:

Month Day Year
Date
Phone Number
Please enter a valid phone number.
PARENT/GUARDIAN INFORMATION:
Father/Guardian Full Name:

First Name Last Name
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mother/Guardian Full Name:

First Name Last Name
Cell Phone Number:
Please enter a valid phone number.
Home or Work Phone Number:
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
EMERGENCY INFORMATION:
Emergency Contact Person:
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Student:
Student’s Physician:
Name:
Phone Number
Please enter a valid phone number.
Student's Dentist:
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Medical Insurance Information
Do you have medical insurance? *
If yes, please provide your insurance information below:
Name of Insurance Company, Client Information, Group Number
If no, you will be responsible for any emergency charges. Please sign below.
Does your child take any prescription medication which needs to be administered while at Youth Conference? If yes, please explain the type of medication, dosage, and who will administer the medication.
MEDICAL HISTORY:

Please complete the following section if your student has any dietary or medical needs:
Does your student have any of the following medical issues: Diabetes, seizures, allergies, mental or emotional disturbances, etc? If yes, please explain:
Please list any special dietary needs:
My child has permission to take over the counter medication:
In case of serious emergency or illness, when the parents cannot be reached immediately, I hereby authorize Liahona to obtain emergency medical care--i.e., physician, dentist, paramedic, or other authorized ememrgency agents, and hereby release Liahona from any resulting liability.
Signature of Parent or Guardian *

Clear
2464 West 450 South Pleasant Grove, UT 84062 www.LiahonaEducation.com (801) 785-7850 Office (801) 406-0071 Fax
Should be Empty:

Distance Education Student Medical Form

STUDENT INFORMATION:

PARENT/GUARDIAN INFORMATION:

Emergency Contact Person:

Student’s Physician:

Student's Dentist:

Medical Insurance Information

MEDICAL HISTORY: