HEALTH FORM
WILSHIRE STUDENT MINISTRY July 2023-June 2024
You'll be asked for date of last tetanus shot and upload an insurance card.
Date
/
Month
/
Day
Year
Date
Youth's full name
Birth date
/
Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Youth's Phone
Parent Name
*
Parent Cell Phone
*
Parent Name
Parent Cell Number
Please enter a valid phone number.
Please list an additional emergency contact name
*
Emergency contact's phone
*
Relationship to Youth
1. Does your youth have any medical problem such as diabetes or asthma that the sponsors should know about? If so, explain and give instructions for care.
2. Is your youth taking any medication routinely?
YES
NO
If so, what medication is your youth bringing on the trip?
3. Please list any food or drug allergies.
4. Provide the date (month/year) of your youth's last Tetanus shot. (Please do not list "current", medical staff will need to know a specific date.)
5. Other information you would like us to know about your youth:
6. Please upload and front back copy of an insurance card.
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