SAPC YOUTH INFORMATION & MEDICAL FORM

SAINT ANDREWS PRESBYTERIAN CHURCH
YOUTH INFORMATION FORM
Youth's Name
Date of Birth

MonthDayYear
Date
Age
School
Grade
Address
Parent/Guardian's Name(s)
Parent/Guardian Phone number(s)
Parent/Guardian Email(s)
example@example.com
PERMISSION, MEDICAL AND LIABILITY RELEASE STATEMENT
Igive my permission for my child to participate in any local event on any date with Saint Andrews Presbyterian Church Youth Ministry. I understand that activities may involve risk of personal injury and/or property damage, or loss of person or property. And I hereby waive and release all claims or rights against Saint Andrews Presbyterian Church, its officers, directors, coordinators, adult volunteers, and all owners of equipment which may be used in this event for any and all injury, damage or loss of person or property incurred during this event. I understand that all participants are expected to conduct themselves in appropriate manner and to obey the adult chaperones. I understand that I will be contacted as soon as possible concerning any medical or behavioral problem with my child. I understand that photos and recordings from Saint Andrews Presbyterian Church's programs and events might be placed in a variety of media, which may be available on the internet. Saint Andrews does not identify individual's names, unless previously agreed upon by the individual, or if under 18, the individual's parent/guardian. I give my permission for, and will accept financial responsibility for, SAPC staff adult chaperones to act in my behalf in the event of a medical emergency for my child. I have reviewed the information that is on the Medical Information Form, and it is correct to the best of my knowledge.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
SAINT ANDREWS PRESBYTERIAN CHURCH
YOUTH MEDICAL & EMERGENCY FORM
Youth's Name
Birth Date

MonthDayYear
Date
Insurance Company
Policy
Policy Holders Name
Employer (if group plan)
Insurance Phone #
Date of most recent Tetanus shot

MonthDayYear
Date
Physician's Name
Phone
Dentist's Name
Phone
Raleigh Hospital Preference
Current Medications & Schedule
Known allergies
Special Dietary needs
Emergency Contact Information (if parent/guardian is not available):
Name
Relationship
Phone # (Home)
Phone # (Cell)
I give my permission for Saint Andrews Presbyterian staff/volunteers to provide my child with over-the-counter medication (Advil, Tylenol, Benadryl, Dramamine, Pepto Bismal, etc
I give my permission for Saint Andrews Presbyterian staff/volunteers to provide my child with over-the-counter medication (Advil, Tylenol, Benadryl, Dramamine, Pepto Bismal, etc

YesNo
Parent Signature

Clear
Other pertinent medical history:
Should be Empty:

SAINT ANDREWS PRESBYTERIAN CHURCH

YOUTH INFORMATION FORM

PERMISSION, MEDICAL AND LIABILITY RELEASE STATEMENT

YOUTH MEDICAL & EMERGENCY FORM