Medical Information Form

MEDICAL INFORMATION FORM

(LAST UPDATED 7/18/2022)
Child's Name

First Name Middle Name Last Name
Date of Birth

Month Day Year
Allergies to drugs, food, environmental, insect, etc (indicate none if applicable)
Please list any medications the child is currently taking.

PARENT/GUARDIAN INFORMATION
Parent/Guardian Name
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Insurance Information
Primary Insurance Provider
Name of Policy Holder

DOCTOR INFORMATION
Family Doctor
Family Doctor Phone Number

Area Code Phone Number
Family Doctor Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

IMMUNIZATION RECORDS
Please indicate if your child has received the following immunizations by recording a date. If your child has not been immunized for that disease leave the date blank. If you have chosen not to immunize your student, please sign the "Immunization Religious Exemption Form" below.
Hepatitis
Tetanus
Polio
Diphtheria
Pertussis
HiB
MMR

IMMUNIZATION RELIGIOUS EXEMPTION FORM
INSTRUCTIONS TO PARENTS OR GUARDIANS:

Vaccine preventable diseases continue to exist. Immunizations are one of the most cost effective measures to protect children, adolescents, and adults from harmful vaccine preventable diseases and possible death. A high proportion of children and adolescents must be immunized to prevent outbreaks of disease in school settings and other places where children and adolescents are educated, work, and play close together. A parent or guardian wishing to exempt their child from some or all vaccinations must provide a written statement indicating the religious objections to the vaccination(s). A person who has been exempted from a vaccination is considered susceptible to the disease or diseases for which the vaccination offers protection. This person may be subject to exclusion from school, group facilities or other programs, if the local and/or state public health authority advises exclusion as a disease control measure. By signing this religious exemption form, I acknowledge that I have been educated and received materials regarding the benefits of vaccination. I have had an opportunity to ask questions which were answered to my satisfaction. I further acknowledge that I may be placing myself or my child and others at risk of serious illness should my child contract a disease that could have been prevented through proper vaccination. I feel I understand the risks associated with not receiving the vaccines checked below. I also give permission to share my immunization record and /or Certificate of Religious Exemption with facilities or institutions, which are required by law to have such records and with my other health care provider(s).
By signing my name below, I am attesting that I object to having my child immunized.

Clear
Date

Month Day Year

CONSENT FOR TREATMENT
This form helps us to ensure your child receives appropriate care in your absence if neither you nor your emergency contact can be reached.
I/we the undersigned parents or legal guardian of the above-named student, a minor, do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital services that may be rendered to said minor under the general or special supervision of any physician and surgeon, licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at the licensed hospital. It is understood that reasonable effort will be made to contact the doctor listed before any other physician is called by the school or other organization. *

Yes
It is further understood that this consent is given in advance of any specific diagnosis, treatment or hospital care which might be required, but is given to provide authority to the treatment or hospital care which might be required, but is given to provide authority to Centerville Christian School or the physician to exercise their best judgment as to the requirements of such diagnosis and treatment. It is further understood that reasonable effort be made to contact parents/guardians or emergency contact prior to using this consent. *

Yes
I understand that as the parent or legal guardian I am responsible any fees incurred not covered by insurance. *

Yes
I/we hereby authorize any hospital, physician, or other person who has attended or examined the minor to furnish to the General Conference Insurance Service, or its representative, any and all information with respect to any illness, medical history, consultation, prescriptions or treatments, and copies of all hospital or medical records. A photostatic copy of this authorization shall be considered as effective and valid as the original. *

Yes
I/we hereby authorize any hospital or physician which has provided treatment to the above named minor to surrender physician custody of such minor to the above agent upon completion of treatment. *

Yes
By signing my name below, I am stating that I agree with the terms of this Consent to Treat form. *

Clear
Date *

Month Day Year
Should be Empty:

MEDICAL INFORMATION FORM

INSTRUCTIONS TO PARENTS OR GUARDIANS: