Student Medical Form

KW E-mail

Student Name

Date of Birth

Month Day Year

Grade Now

Biological Sex

male female

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Parent Email

(A copy of this medical form will be sent to email provided.)

EMERGENCY CONTACT 1

Emergency Contact 1 Name

Phone Number

Area Code Phone Number

Relationship

i.e., father, mother, grandfather

EMERGENCY CONTACT 2

Emergency Contact 2 Name

Phone Number

Area Code Phone Number

Relationship

i.e., father, mother, grandfather

MEDICAL CARE

List all allergies (food, drugs, insects, etc.)

Is this student diabetic?

yes no

Does this student take insulin?

yes no

Is this student taking any type of medication?

yes no

If so, what medication? For what? How often?

Has this student ever had surgery?

yes no

If so, what was it for?

Does this student have any chronic disease or illness (blackouts, fainting, epilepsy, etc.)? If so, please describe in detail.

When was your student last vaccinated for tetanus?

Date

Family Physician Name

Family Physician Phone

Area Code Phone Number

Please provide any additional important medical or other information concerning this student, which you feel may help NEHBC care for them more effectively.

MEDICAL INSURANCE

Insurance Company

Group #

Policy #

Phone # of Insurance Company

Area Code Phone Number

MEDICAL AUTHORIZATION

In the event of a change in the medical condition of my student, I will notify in writing Northeast Houston Baptist Church (NEHBC) prior to my student's participation in future events. I understand that I can revoke this medical authorization at any time upon writing to NEHBC.

I hereby give permission to NEHBC and the physician selected by NEHBC representative to secure medical treatment that may be deemed necessary to ensure my student's well-being (including hospitalization and surgery). I, the undersigned, do hereby release NEHBC from any and all claims, demands, actions or cause of action arising out of damage or injury while my student participates in NEHBC sponsored activities.

Signature Authorizing Medical Care - use mouse (computer) or finger (touch-screen devices) to sign *

MEDIA USE AUTHORIZATION

Every year, the NEHBC Student Ministry uses photographs and videos of our students for a variety of projects and media, including social media networks such as Facebook, Twitter, and Instagram. In addition, we may use photographs and videos of our students in our NEHBC Student Ministry App, and in printed publications.

Please choose one of the permissions below:

USE ANY - Photographs, images, and/or video of my child may be used in any of the ways identified above, including those prepared for both an internal and external audience. NONE - I DO NOT want my child's photograph, image, or video used in any way. LIMITED PERMISSIONS - I would like to choose the publications for which you may NOT use photographs, images, and/or video of my child.

LIMITED PERMISSIONS - DO NOT use photographs, images, and/or video of my child for the following:

social media app printed publications

Signature Authorizing Media Use - use mouse (computer) or finger (touch-screen devices) to sign *

TRANSPORTATION AUTHORIZATION

NEHBC Student Ministry-sponsored events may include the transportation of students to and from the event location. Because we are committed to the safety of minors, at no time will students be permitted to ride with an adult for an NEHBC Student Ministry-sponsored activity who has not completed our Child Protection Training and a Driver's Background Check. Please indicate your authorization for the NEHBC Student Ministry to transport your student by signing below:

I give permission for my student to be transported to and from NEHBC sponsored activites by the approved adult in whose care my student has been entrusted to while attending and participating in all NEHBC sponsored activities. I understand that these adults would include NEHBC Student Ministry staff and approved volunteers.

Signature Authorizing Transport - use mouse (computer) or finger (touch-screen devices) to sign *

Student Medical Form

Medical Form - Student 2

Medical Form - Student 3

Medical Form - Student 4