Medical Form (2025

Student's Full Name*
I certify the above named child is my child or my legal ward who resides with me. I give my consent for him/her to participate in the Children's / Youth Ministry at Covenant Church. In case of an emergency, I understand that every effort will be made to contact me immediately, should medical care be necessary for my child. I hereby give my consent for an adult with Covenant Church, and/or qualified medical personnel to act on my behalf in securing and administering necessary first aid or emergency medical care and treatment for my child. I also release all sponsors, staff, counselors, and members of Covenant Church, Inc. from any responsibility, liability, and medical payments in acting on my behalf in this regard. This form will remain in effect while my child is a participant in the Covenant Church Children's/Youth Ministry. understand that this form will be kept on file at the church and a copy is carried on all trips and outings. All information is confidential and will only be released to leaders in charge of my child and appropriate medical personnel. I have read, understand and agree to the above statement.
Parent Legal Guardian Signature*
STUDENT INFORMATION
Date of Birth*

MonthDayYear
Address*
City, State (Zip Code)*
Social Security Number*
Email Address
example@example.com
Home Phone*
Format: (000) 000-0000.
PARENT / GUARDIAN INFORMATION
Parent / Guardian Name*
Address (if different from above)

Address

Street Address Line 2

City, State (Zip Code)State / Province

Postal / Zip Code
Home Phone (if different from above)
Format: (000) 000-0000.
Mobile Phone*
Format: (000) 000-0000.
Email Address*
Workplace
Work Address
Work Phone
Format: (000) 000-0000.
Parent / Guardian Name
Address (if different from above)

Address

Street Address Line 2

City, State (Zip Code)State / Province

Postal / Zip Code
Home Phone (if different from above)
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
Email Address
Workplace
Work Address
Work Phone
Format: (000) 000-0000.
Emergency Contact & Phone Number (For use in the event that parent / legal guardian is unavailable)
Name*
Relationship to family*
Phone Number*
INSURANCE INFORMATION
Covenant Church requires that any student participating in a Children's/Youth Ministry event be covered by major medical insurance. It is important to note that should the need arise for medical attention, your insurance carrier is the primary provider, and Covenant Church's insurance carrier will be secondary to any expenses not covered by your company. Please attach a front & back copy of your insurance card to this form.
Insurance Company*
Insurance Company Phone*
Format: (000) 000-0000.
Policy Group Number*
Policy Holder*
MEDICAL HISTORY
Family Doctor*
Doctor's Phone*
Format: (000) 000-0000.
In the event that my student needs to receive prescription medicines, I give permission for my student to receive the following prescription medications, which will be administered only in accordance with the package's label. PLEASE NOTE: An adult counselor of the Children's/Youth Ministry Team must be made aware of any prescription medicine that is to be taken during an outing. Prescription medications must be in their original packages along with specifics of any dosage changes.
Please give a list of prescription medicines and dosages which your student is currently taking:
Acetaminophen (Tylenol)Ibuprofen (Advil)Triple Antibiotic Ointment (Neosporin)Diphenhydramine (Benadryl)Bismuth Subsalicylate (Pepto-Bismol)Loperamide (Imodium AD)Pseudoephedrine (Sudafed)
List any other medicines NOT to be given:
Food allergies (specify below)Drug allergies (specify below)Environmental allergies (specify below)Physical limitations (specify below)Other (specify below)
Enter specifics here:
I have read, understood and completed this form to the best of my knowledge.*
Date*

MonthDayYear
Please upload both sides of your insurance card.

Cancelof

INSURANCE INFORMATION

MEDICAL HISTORY

Media Release