Middle School Ministry Registration Form 2018-19

ADDRESS: *

HOME NUMBER: (xxx-xxx-xxxx) *
CHILD LIVES WITH: *

Both Parents Mother Father Stepmother Stepfather Grandparent(s) Guardian

Medical Information
Is this child in good health and able to participate in all activities in Middle School Ministry? *

Yes No (Please submit statement below)
If no, please submit a statement indicating the limitation or serious medial condition(s).
MEDICATION: Please list any medication(s) that might need to be administered. Name of medication (over-the-counter and/or prescriptions) including dosage and frequency.
Please list any notable operations or serious Injuries: (Please include dates)
Please list any special dietary needs:
Please describe any learning issues:
Date of most recent physical exam:

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Name of Physician/Clinic:
Physician/Clinic Address:
Physician/Clinic Phone Number: (xxx-xxx-xxx)
Family Health Insurance Company:
Policy Number:
Date of DPT Booster

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Date of DPT

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Date of Tetanus Booster

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ALLERGIES or ILLNESSES

Hay Fever Asthma Sulfa Nuts Penicillin Gluten
Treatment: If any of the above is a yes, please state how the child has been (should be) treated and with what medication.

Address for Church of Baptism:

Address for Church of First Eucharist:

LAST GRADE OF RELIGIOUS EDUCATION:
HOME PARISH: *
MSM SESSION PREFERENCE:

Wednesday, 7:00 pm - 8:30 pm Thursday, 3:30 pm - 5:00 pm

Family Information