Nextdoor Youth SMERF

Nextdoor Church of the Nazarene

S.M.E.R.F. [Student Medical Emergency Release Form)
Parent/Guardian's Name

First NameLast Name
Phone(s)
Parent Guardian's Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Health Insurance Company
Policy #
Group #
Student Name
Gender

MaleFemale
Address, City, Zip
Student Phone Number
Please enter a valid phone number.
School
Grade
Birthday
Student Email
example@example.com
Shirt Size
Signature of Parent/Guardian

Powered by Jotform SignClear
Date
Signature

Powered by Jotform SignClear
Date
Nextdoor Church of the Nazarene

S.M.E.R.F. (Student Medical Emergency Release Form)
IF PARENT / GUARDIAN IS UNREACHABLE IN AN EMERGENCY, THE FOLLOWING INDIVIDUAL(S) WILL BE CONTACTED
Emergency Contact 1
Relationship
Phone
Emergency Contact 2
Relationship
Phone
Family Doctor
Phone
City
Any Medical Conditions to be aware of such as (Diabetes; Impaired Vision; Frequent Stomach Aches; Heart Condition; Asthma; Hearing Loss; Drug Allergies; Epilepsy; Seasonal Allergies; Anxiety; Depression; Food Restrictions/Allergy; or any other).
Medical Conditions
If you checked any of the above, please give details (include extent of issue & normal treatments)
List any pre existing medical conditions or allergies that my be relevant in the event of injury
Date of Last Tetanus Shot
Does your child wear contact lenses?
Name, Dosage, and Time for any Medications
Child's swimming ability (poor, good, average, excellent)
Explain any activity restrictions that your child may have
Heading
Should be Empty:

IF PARENT / GUARDIAN IS UNREACHABLE IN AN EMERGENCY, THE FOLLOWING INDIVIDUAL(S) WILL BE CONTACTED

Heading