Youth - 2025-2026 Trinity Cathedral Medical Form

Trinity Cathedral Medical Form

Medical information and consent to treatment: Program Year 2025-2026
This form when completed will be utilized and relied upon for all Trinity Cathedral trips and events for the 2025-2026 Program Year. You need only to submit this form once during this time. If medications or your child's health situation changes during the program year, please notify the appropriate program area administrator and submit an updated Medical Form.
Participant name

First NameLast Name
Participant's grade and name of school for 2025-2026 school year
Social Security # (SSN needed only if participant does not have insurance)
Date of Birth:
Gender:

FemaleMaleOtherChoose not to respond
Parent/Guardian name (1)
Cell #
Email address
Parent/Guardian name (2)
Cell #
Email address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical information
Does the participant take any medication?

yes (please describe below)no
Please list any medications (including over-the-counter or non-prescription drugs) taken routinely. For overnight trips, bring enough medication to last the duration of the trip. Keep medications in their original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.
Med #1
Dosage
Specific times per day/reason for taking/other notes
Med #2
Dosage
Specific times per day/reason for taking/other notes
Med #3
Dosage
Specific times per day/reason for taking/other notes
Does the participant have a medical history or restrictions that may limit participation/affect them while on a trip/at an event? (If yes, please describe below)
General Health Questions

(please explain below, if needed)
Has/does the participant:

had any recent injury, illness, or infectious disease?have a chronic or recurring illness/condition?ever been hospitalized?ever had surgery?have frequent headaches?ever had a head injury?ever been knocked unconscious?wear glasses, contacts, or eyewear?ever had frequent ear infections?ever passed out during or after exercise?ever been dizzy during or after exercise?ever had seizures?ever had chest pain during or after exercise?ever had high blood pressure?ever been diagnosed with a heart murmur?ever had back problems?ever had joint problems?plan to bring an orthodontic appliance to trip?have any skin problems?have diabetes?have asthma?had mononucleosis in the last 12 months?had problems with diarrhea or constipation?have problems with sleepwalking?(if applicable) have an abnormal menstrual history?have a history of bed-wetting?ever had an eating disorder?ever sought professional help with emotional difficulties?
Please explain, if needed:
General health questions (please check those that apply to the participant)

chest painhematologicalgastrointestinalmusculoskeletalrespiratorylymphaticgenitourinarycardiac diseaseneurologicalweight gainweight losscardiovascularpsychiatricother
Check the conditions that apply to you or any member of your immediate relatives:

asthmacardiac diseasehypertensionepilepsycancerdiabetespsychiatric disorderother
Dietary restrictions:

vegetarianveganother
Please describe any other dietary restrictions:
Please list any food allergies:
Which of the following has the participant had?

measleschicken poxmumpshepatitis Ahepatitis Bhepatitis C
Which of the following immunizations has the participant had?

DTPMMRRubellahaemophilus influenza BCOVID-19poliomeasleshepatitis BTD (tetanus / diptheria)mumpsvaricella (chicken pox)
Date of last tetanus shot:

MonthDayYear
Date
Health care information
Name of regular physician or health care facility
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is the participant covered by an insurance plan?

yesno
Insurance carrier:
Group #:
Policy #:
Insurance carrier address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of insured/policy holder
Relationship to participant:
Use this space to provide any additional information about the participant of which Trinity Cathedral and trip/event leaders should be aware:
Parent/Guardian Authorization & Acknowledgement of Risk
I give permission to the medical personnel selected by the leader of the trip/event or the designee to provide routine health care; to administer medications; to order X-rays, routine test(s) and treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. I acknowledge that there are inherent risks to participation in recreational and adventure activities and programs sponsored by Trinity Cathedral, including but not limited to swimming, canoeing, climbing, and ropes courses which could result in accidental injury, possibly serious. Parents will be notified immediately of a serious injury. Furthermore, engagement in these activities requires good physical condition on behalf of my child. I am aware of the inherent risks and potential injury to my child while attending and participating in the activities sponsored by Trinity Cathedral.
Signature of parent/guardian
Signature of participant (if more than 21 years of age)
Should be Empty:

Trinity Cathedral Medical Form

Medical information

General Health Questions

Health care information

Parent/Guardian Authorization & Acknowledgement of Risk