LEAD: Medical Form

Medical Information & Parental Permission for Treatment Form
Participant's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone*
Parent or Guardian's Contact Information: Please list contact information for two primary guardians
Guardian's Name

First NameLast Name
Relationship to Participant
ex. mother, father, grandmother etc.
Address

Address Same as Participants (if different please list below)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone
Daytime Phone
Evening Phone
Parent or Guardian's Name

First NameLast Name
Relationship to Participant
ex. mother, father, grandmother etc.
Address

Address Same as Participants (if different please list below)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone
Daytime Phone
Evening Phone
Emergency Contact: Please list a relative, neighbor or friend in case parents cannot be reached.
Emergency Contact:
Emergency Contact:

First NameLast Name
Relationship to Participant
Cell Phone
Other Number for Contact

Allergies or Medical Conditions we should be aware of (check all that apply):

AsthmaConvulsionsDiabetesFainting SpellsInsect StingsAllergies
Allergic reaction to medicines?

YesNo
If yes, please list all medicines you are allergic to:
Other medical issues we should be made aware of:
Current medications you are taking that we need to be aware of:
Do you have any food restrictions?
Please note: LEAD Four:Twelve staff are not responsible for dispensing medicine.

Family Insurance Information
Company Name:
Policy Holder:
Policy or Group Number:
Other Insurance Information:
Parental Electronic Signature
My child has my permission to attend all LEAD Four:Twelve (a ministry of the Jeremiah Project) retreat and events. In the case of a medical emergency, I understand that every effort will be made to contact my child's parent(s) or guardian(s). In the event that neither I, nor the emergency contact person listed above, can be located, I hereby give permission for the LEAD Four:Twelve Coaches/Leaders with consultation from the on-site RN to select a physician, to hospitalize, to secure proper treatment for, and to order injection, anesthesia or surgery for my child. (This information will be required in the event that the participant listed above is taken for medical treatment.) Jeremiah Project insurance serves as a secondary coverage. I release the following from any liability in the event of an accident or injury en route to, during and/or returning from LEAD Four:Twelve activities, both work and recreational related: The Jeremiah Project, Inc. and all staff persons connected within, all adult leaders, chaperones, and/or churches.
Name of Child:
Electronic Signature of Parental Guardian for LEAD Four:Twelve Participant:
I agree to the above statement.
Please confirm the accuracy of your answers before submitting this form!
Note to Parents/Guardians: If any of this information changes while your student is in LEAD Four:Twelve, you will need to fill out a new medical form. Please also email todd@jeremiahproject.org to ensure we have updated your student's medical form.
Should be Empty:

Medical Information & Parental Permission for Treatment Form

Parent or Guardian's Contact Information: Please list contact information for two primary guardians

Emergency Contact: Please list a relative, neighbor or friend in case parents cannot be reached.

Family Insurance Information

Parental Electronic Signature