Form B: Medical Information 2026 2027

Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical Information

This form should be completed for any person (under 19 years of age) in parish religious education, Catholic schools, and youth ministry programs and should be completed on an annual basis at the beginning of the program.
Parish
School
Participant's ( Student's) Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place of Birth
Physician's Name (first, last)
Physician's Phone (including area code)
Format: (000) 000-0000.
Please list any medical conditions of the participant (asthma, diabetes, epilepsy, etc)
List below any physical condition the sponsors, doctors, nurses, or other medical personnel should be aware of:
Insect stings
Fainting spells
Allergies
Ear infections
Seizures
Heart condition
Headaches
OTHER
List any allergies or allergic reactions to medications of the participant
Other pertinent medical information
Date of Participant's last immunizations: MMR
MMR
TB
TETANUS
Special dietary needs/restrictions
Prescribed medication now being taken:
Type
Dosage
How often
Activities individual should not participate in
Medical Insurance Information:
Insurance Company
Plan Number
Employee Identification #
Policy Holder's Name
Policy Holder's Daytime Phone (including area code)
Format: (000) 000-0000.
Policy Holder's Cell Phone (including area code)
Format: (000) 000-0000.
Other Contact Name (first, middle, last)
Cell Phone (including area code)
Format: (000) 000-0000.
Relationship (friend, neighbor, coworker, etc)
Should be Empty: