HVCOC Youth Group Medical Form

HVCOC Youth Group Medical Form

2025
Student Name

First NameLast Name

Age:
Grade:
Gender:
Birth Date

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

Medical Insurance Company:
Policy #:
Physician Name:
Physician Office Phone Number
Please enter a valid phone number.
Dentist Name:
Dentist Office Phone Number
Please enter a valid phone number.
Mother's Name:
Mother's Phone Number
Please enter a valid phone number.
Father's Name:
Father's Phone Number
Please enter a valid phone number.
Emergency Contact Name:
Emergency Contact Phone Number
Please enter a valid phone number.

Medical History

Explain the following areas of concern for this student.
Please list and explain any allergies your child has. (ex. pollens, food, medication, insect bites)
Please explain any persistent medical problems your child currently has or has experienced. (ex. asthma, epilepsy/seizure disorder, heart condition, diabetes, disability)
Please list any medications your child is currently taking.
Date of last tetanus shot.
Should this child's activities be restricted for any reason? Are there any activities that this child should not participate in? Please list and explain. Note: Please remind chaperones of these restrictions before youth group events and activities.
Additional Comments:

Medical Release and Permission Form
For your information, we expect each student to conform to these rules of conduct.

No Possession or use of alcohol, drugs, or tobacco

No students can drive without pre-approved permission

No fighting, weapons, fireworks, lighters, or explosives

No offensive or immodest clothing

Participation with the group is expected

Respect propoerty

Repsect one another, staff and adult leaders

Respect and comply with event schedules

Students who fail to comply with these expectations may be sent home at their parents' expense.
I (Student Name) blanks have read the rules of conduct, the above evaluation of my health and permission to participate in youth group activities. I agree to abide by the stated personal limitations and code of conduct.
Student Signature

Clear
The student named above has my permission to participate in youth group activities.

This consent form gives permission to seek whatever medical attention is deemed necessary,and releases the Hardin Valley Church of Christ and its staff of any liability against perosnal losses of named child.

I/We the undersigned have legal custody of the student named above, a minor and have given our consent for him/her to attend events being organized by the Hardin Valley Church of Christ. I/We understand that there are inherent risks involved in any ministry or athletic event,and I/We hereby release the church, its ministers, adults, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or propoerty that may occur during the course of my/our child's involvement. In the event that he/she is injured and requires the attention of a doctor, I/We consent to any reasonable medical treatment as deemed neccessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/We agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance infomation provider or if I/We do not carry any health insurance. Further, I/We affirm that the health insurance information proided above, if applicable, is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if demed necessary by the youth ministries staff member.
Parent/Guardian Signature and Date

Clear
Please submit in writing any changes that occur in your health insurance policy.
Should be Empty:

HVCOC Youth Group Medical Form

Medical History

Medical Release and Permission Form