Adult Med Form

Adult Medical Form

NEHBC Student Ministry
KW E-mail
Name
Date of Birth

MonthDayYear
Age Now
Biological Sex

malefemale
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number

Area CodePhone Number
Phone Number 2 (optional)

Area CodePhone Number
Email (optional)
A copy of this form will be sent to email provided.
EMERGENCY CONTACT 1
Emergency Contact 1 Name
Phone Number

Area CodePhone Number
Relationship
i.e., spouse, parent
EMERGENCY CONTACT 2
Emergency Contact 2 Name
Phone Number

Area CodePhone Number
Relationship
i.e., spouse, parent
MEDICAL CARE
List all allergies (food, drugs, insects, etc.)
Are you currently taking any medication?

yesno
If so, what medication? For what? How often?
Please provide any additional important medical or other information, which you feel may help NEHBC care for you more effectively.
MEDICAL INSURANCE
Insurance Company
Group #
Policy #
Phone # of Insurance Company

Area CodePhone Number
MEDICAL AUTHORIZATION

In the event of a change in my medical condition, I will notify Northeast Houston Baptist Church (NEHBC) in writing. I understand that I can revoke this medical authorization at any time upon notice in 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 well-being. 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 participating in NEHBC sponsored activities.
Signature Authorizing Medical Care - use mouse (computer) or finger (touch-screen devices) to sign*
Should be Empty:

Adult Medical Form