Emergency Medical Form

Emergency Medical Form

Please fill in the form below.
Student Information
Student's Full Name

First NameLast Name
Student's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian & Emergency Contacts
Parent/Guardian Name

First NameLast Name
Parent/Guardian E-mail:
Parent/Guardian Mobile Phone

Area CodePhone Number
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Alternate Emergency Contact Name + Relationship
Alternate Emergency Contact Phone

Area CodePhone Number
Father's Work Phone

Area CodePhone Number
Mother's Work Phone

Area CodePhone Number
Medical Information
Insurance Co:
Insurance Card #:
Insurance Policy #:
Doctor's Name:
Doctor's Address:
Doctor's Office Phone:

Area CodePhone Number
Medical History

Has your student ever had any of the following:
Appendicitis
Asthma or Hay Fever
Hernia (Rupture)
Rheumatic Fever
Diabetes
Does Student take insulin
Poliomyelitis
Heart Trouble
Scarlet Fever
Sever Allergies
Significant Disease, Injury or Operation
Medical History that requires medication
Any activities restricted due to medical
Pre-existing Conditions

Is your student subject to any of the following:
Sinus Trouble
Fainting Spells
Ear Trouble
Convulsions
Poison Ivy, Oak or Sumac
Reaction to Penicillin
Nervousness/Easily Upset
Allergies
Date of last Tetanus Shot
If you answered "Yes" to any questions, please explain:
Parent/Guardian Authorization
I certify that I am the parent or legal guardian of the student named above and that the information provided on this form is accurate to the best of my knowledge.

In the event of illness or injury during a Jubilee Christian Center activity, I authorize church staff and designated ministry leaders to contact emergency services and arrange necessary medical evaluation, transportation, and care for my child.

I understand that reasonable efforts will be made to contact me promptly. If I cannot be reached, I authorize licensed medical professionals to provide medically necessary emergency treatment to the extent permitted by law.

I acknowledge that I have read and understand this authorization.
Parent/Legal Guardian Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Emergency Medical Form

Student Information

Parent/Guardian & Emergency Contacts

Medical Information

Medical History

Pre-existing Conditions

Parent/Guardian Authorization