Campus Life Mandatory Health Form

CAMPUS LIFE

Denver Area Youth for Christ Mandatory Health Form
STUDENT INFO
School*
Today's Date*

MonthDayYear
Date
Name of Student*
Date of Birth*

MonthDayYear
Date
Address*
City*
State*
Zip*
Phone*
Sex*
Height*
Weight*
EMERGENCY CONTACT PERSON
Parent/Guardian Name*
Address (if different than student)
City
State
Zip
Phone (home)*
Phone (work)
EMERGENCY CONTACT PERSON

Use someone near the primary contact.
Name*
Relationship to student*
Address (if different than student)
City
State
Zip
Phone (home)*
Phone (work)
MEDICAL INSURANCE

If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your child is at the activity/trip.
Do you have health insurance?

YESNO
Insurance Company Name
Policy Holder's Name
Policy Number
Family Doctor
City
Zip
HEALTH HISTORY
Check if student has history with any of the following:

Hay FeverHeart ConditionDiabetesInsect StingsEpilepsy/Nervous DisordersFrequent Stomach UpsetsPhysical HandicapOther
Does student have any allergies? If so, please list below.
If any of the above are checked, please give details (including normal treatment of allergic reactions)
Any major illnesses during the past year?
Name and dosage of any medications that must be taken:
PARENT PERMISSION AND MEDICAL LIABILITY RELEASE STATEMENT
As parent/legal guardian of blanks* , I have reviewed the information about the youth ministry activity/event and give my permission for the subject of this release to be involved in the overall activities connected with the event.
I have reviewed the rules of the activity and agree that the subject of this release will abide by them. I also acknowledge that if the subject of the release has to return home early for discipline violations, it will be at my expense.

I consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the subject of this release during the activity/event to be used, distributed, or shown as Youth For Christ determines.

I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached, in an emergency, during the activity/event dates shown on this form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment, and/or order an injection, anesthesia, or surgery for my child as deemed necessary.

I understand all reasonable safety precautions will be taken at all times by Denver Area Youth For Christ and its agents during events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Youth For Christ, its leaders, its employees, and/or volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
MEDIA RELEASE
I hereby grant permission to Denver Area Youth For Christ the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of Denver Area Youth For Christ.
BEHAVIORAL AGREEMENT
I understand that illegal or immoral activities or behavioral issues may result in the named participant being sent home at the expense of the parent(s)/guardian(s). (These activities would include but not be limited to the possessions and/or use of drugs, alcohol or weapons, sex outside of the marriage relationship, stealing, fighting, etc.) YOUTH FOR CHRIST/USA INC. will make efforts to contact the parent(s)/guardian(s) to make arrangements before the named participant is sent home.
MEDICATION INFORMATION
Any medication brought to a Denver Area Youth For Christ trip must be accompanied by written instructions from a physician/parent All prescriptions must be brought to camp in the original container in which they were issued (with medical instructions, dosage information, etc.)
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Signature of Student (if over 18 years of age)

Clear
Date

MonthDayYear
Date
Should be Empty:

CAMPUS LIFE

STUDENT INFO

EMERGENCY CONTACT PERSON

EMERGENCY CONTACT PERSON

MEDICAL INSURANCE

HEALTH HISTORY

PARENT PERMISSION AND MEDICAL LIABILITY RELEASE STATEMENT

MEDIA RELEASE

BEHAVIORAL AGREEMENT

MEDICATION INFORMATION