Form B- Medical Information 24-25

Date*

Date

Medical Information

This form should be completed for any person (under 19 years of age) in parish religious education, Catholic schools, and youth programs and should be completed on an annual basis at the beginning of the program.

Parish*

School*

Participant's ( Student's) Name*

Date of Birth*

Date

Place of Birth*

Physician's Name (first, last)*

Physician's Phone (including area code)*

Please list any medical conditions of the participant (asthma, diabetes, epilepsy, etc)

List below any physical condition the sponsors, doctors, nurses, or other medical personnel should be aware of:

Insect stings

Fainting spells

Allergies

Ear infections

Seizures

Heart condition

Headaches

OTHER

List any allergies or allergic reactions to medications of the participant

Other pertinent medical information

Date of Participant's last immunizations: MMR

MMR

TB

TETANUS

Special dietary needs/restrictions

Prescribed medication now being taken:

Type

Dosage

How often

Activities individual should not participate in

Medical Insurance Information:

Insurance Company*

Plan Number*

Employee Identification #*

Policy Holder's Name*

Policy Holder's Daytime Phone (including area code)*

Policy Holder's Cell Phone (including area code)*

Other Contact Name (first, middle, last)

Cell Phone (including area code)

Relationship (friend, neighbor, coworker, etc)