2024-2025 St. Ann Youth Medical Form

2024-2025 Medical Form

We ask parents to fill this out completely so we may use this information for all events your teen attends during the 2024-2025 academic year (Retreats, Life Nights, Edge Nights, Conferences, Mission Trips, etc). If any of the following information changes, please fill out a new form. Thank you.
Teen Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
My teen is in:*
High School Graduation Year*
High School*
Teen Email*
example@example.com
Grade for 2024-2025*
Middle School*
T-Shirt Size*

SmallMediumLargeXLXXL
Parent Name*

First NameLast Name
Parent Cell*

Area CodePhone Number
Parent E-mail*
I. The undersigned does hereby give permission for our (my) child to attend and participate in activities sponsored by the St. Ann's YOUTH MINISTRY Programs. II. We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any licensed physician or dentist. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered. III. I hereby grant permission for non-prescription medication to be given, if deemed appropriate. IV. Should it be necessary for our (my) child to return home due to medical reasons, behavioral reasons, or otherwise the undersigned shall assume all transportation costs. V. The undersigned does also give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the St. Ann's YOUTH MINISTRY Programs.*

I agree
Insurance Provider*
Name with Insurance*
Insurance Number*
Group Number*
Allergies?*
I give permission for my teen to be photographed during activities with St. Ann’s Youth Ministry. I understand that said photos/videos may be used for future Youth Ministry publications within the St Ann’s Community and social media.*

I agree
I give permission for Youth Ministry Staff and volunteers to communicate with my teen via e-mail, phone calls, Zoom, and social media.

I agree
In signing this form, I the parent/guardian, certify that all information contained herein is true and accurate to the best of my knowledge. Please sign below:*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

2024-2025 Medical Form