Male / Female
circle one
(Last, First)
Name:_____________________________________________ Date of Birth:_________________
Address:_______________________________________________________ Grade of Fall 2015: ________________________
City:_______________________________________________________ State:_____________ Zip:_____________________
Emergency Contact Information - MANDATORY
Parent/Guardian:_________________________________________ Email:__________________________________________
Home: (
)________ - __________
Work: (
)________ - __________
Cell: (
)________ - ___________
Second Parent:__________________________________________ Email:__________________________________________
Home: (
)________ - __________
Work: (
)________ - __________
Cell: (
Name ___________________________
General Information please print in ink
)________ - ___________
Alt. Emergency Contact:___________________________________ Relationship to student:__________________________
Home: (
)________ - __________
Work: (
)________ - __________
Family Doctor/Clinic:__________________________________________________
Cell: (
)________ - ___________
Phone: (
)________ - __________
(Contact info for medical records in case of emergency)
Health History To be completely by Parent/Legal Guardian if Student is Under 18
CIRCLE Yes or No
Please explain anything circled yes on the lines below
No
14. Ear/Hearing Problems
Yes
No
27. Eye/Vision Problems
Yes
No
2. Birth Defects
Yes
No
15. Ear Infections
Yes
No
28. Previous Surgeries
(When and for what?)
Yes
No
3. Diabetes
Yes
No
16. Frequent nosebleeds
Yes
No
No
Yes
No
17. Constipation
Yes
No
29. Previous Hospitalizations
Including Psychiatric Care
(When and for what?)
Yes
4. Frequent Headaches
5. Migraine Headaches
Yes
No
18. Diarrhea
Yes
No
30. Physical Handicaps
Yes
No
6. Drug Allergies*
Yes
No
19. Bladder Control Problems
Yes
No
31. Asthma*
Yes
No
7. Hay Fever
Yes
No
20. Frequent upset stomach
Yes
No
32. Other
Yes
No
8. Food Allergies*
Yes
No
21. Infections of any kind
Yes
No
9. Allergies to Insect Bites*
Yes
No
22. Ulcers
Yes
No
10. Other Allergies*
Yes
No
23. Heart Problems
Yes
No
11. Frequent colds and flu
Yes
No
24. Sleep Disorders
Yes
No
12. Frequent sore throat/strep
Yes
No
25. Bone/Joint Problems
Yes
No
13. Frequent sinus problems
Yes
No
26. Convulsions/Seizures
Yes
No
*Please fill out detailed information on the
Prescription Medication and Allergy Form
*Provide any other important health information
Grace Church should know about below.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
33. Do you have any activity restrictions?_______ If yes, what? And why?
34. Do you have any special food requirements or food restrictions? _______If yes, what?
Is this a _______ medical allergy or _______ health preference? If allergy, what allergic reaction do you have?
HEALTH FORM
Yes
Grace Church Student Ministries
Effective June 2015-May 2016
1. Chicken Pox
Medical Permission & Insurance
PERMISSION
Must be initialed and signed in order for student to be allowed to participate
We verify that this form has been truthfully completed to the best of our knowledge. We hereby give permission to the physician or
dentist selected by Grace Church staff to hospitalize, secure proper treatment and/or order an injection, anesthesia, or surgery, and
disclose protected medical information for __________________________________ (name of child) to Grace Church staff and medical
volunteers for the purpose of treating the health and well being of the aforementioned person. We realize and appreciate that there
is a possibility of complications and unforeseen consequences in any medical treatment, and we accept and assume any such risk for
and on behalf of ourselves and said minor. We understand that the information used or disclosed may be subject to re-disclosure by
Grace Church staff or medical volunteers receiving it, and would then no longer be protected by federal privacy regulations. We may
revoke this authorization by notifying Grace Church in writing of our desire to revoke it. However, we understand that any action already taken in reliance on this authorization cannot be reversed, and our revocation will not affect those actions. We understand that
attempts will be made to contact me in the most expeditious manner possible. Permission is also granted to Grace Church staff to
provide needed emergency treatment to the student prior to admission to a medical facility. This authorization begins upon departure
to camp, retreat, or activity within the effective dates specified on this form and expires upon return from said camp, retreat, or activity.
_______ We give permission for the above named student to receive his/her medication according to the prescription or parental
(Initial) request for Over the Counter (OTC) drugs, and any specific instructions. I understand the information is confidential and
only Grace Church staff and medical volunteers, needing to know, have access to this information. I agree to coordinate and
work with Grace Church and the prescriber if questions arise.
_______ We give permission for the nurse or designated Grace Church staff to administer any OTC non-prescription drug according
(Initial)
to the manufacturer’s directions.
_______ We give permission for my son/daughter to self-administer medication, if the nurse or designated Grace Church staff deter
(Initial) mines it is safe and appropriate.
Parent/Legal Guardian Signature: _________________________________________ Date: _____ / _____ / _____
(required if student is under 18 years old)
Parent/Legal Guardian Signature: _________________________________________ Date: _____ / _____ / _____
Participant Signature: __________________________________________________ Date: _____ / _____ / _____
Please complete medical insurance information below.
Parent/Legal Guardian Signature: _________________________________________ Date: _____ / _____ / _____
(required if student is under 18 years old)
INSURANCE
Participant Signature: __________________________________________________ Date: _____ / _____ / _____
Medical Insurance and Dental Insurance Information
Dental Insurance is not required
Medical Insurance Company: _______________________________________________________________________
Policy #: _____________________________________________________________ Co-Pay? ____________________
Name of insured: _____________________________________________________ Birth Date: _____ / _____ / _____
Dental Insurance Company: _________________________________________________________________________
Policy #: _____________________________________________________________ Co-Pay? _____________________
program is voluntary and may involve activities, events or programs that require travel and physical exertion. Such
activities may include, but are not limited to, outings, athletic games, local excursions, service projects, and
meetings. We acknowledge that our child’s participation in any activity involves risks that our child or we may
suffer property damage, bodily injury, or even death. Therefore, in consideration of our child’s being allowed to
participate in the Grace Church youth program and its activities and for other sufficient good and valuable
consideration, we agree to the following:
(Last, First)
(Initial)
________ Grace Church is not responsible for the loss or theft of personal belongings.
(Initial)
________ Misconduct by our child may result in him or her being transported home from an activity at our
expense. A child dismissed for disciplinary reason will not receive a refund of any fee paid for the
(Initial)
activity.
Name ___________________________
_______ The undersigned acknowledge and agree that our child’s participation in the Grace Church youth
________ We understand that our child’s image may be photographed or filmed and consent to use of the
same in video presentations and printed publications of Grace Church or any of its Ministries; including, without
(Initial)
limitation, their internet websites. Please note your child’s full name will not be used in these publications.
Student’s Name: ______________________________________________________ DOB: _____ / _____ / _____
(please print)
Student Signature: ____________________________________________________ Date: _____ / _____ / _____
Parent/Legal Guardian Name: ____________________________________________
Parent/Legal Guardian Signature: _________________________________________ Date: _____ / _____ / _____
(required if student is under 18 years old)
Parent/Legal Guardian Name: ____________________________________________
Parent/Legal Guardian Signature: _________________________________________ Date: _____ / _____ / _____
(required if student is under 18 years old)
LIABILITY RELEASE FORM
________ We, being the parents or guardians of the below-named child. hereby sign this Waiver and Release from Liability
and accept to make the commitments made herein for and on behalf of our child, ourselves, and our respective
(Initial)
successors and assigns as stated more fully above.
Grace Church Student Ministries
Effective June 2015-May 2016
________ We hereby agree and commit to the following for and on behalf of our child, ourselves jointly and severally, and
our and our child’s respective executors, personal representatives, administrators, trustees, heirs, guardians,
(Initial)
conservators, next of kin, successors, and assigns: A) We each waive, release, and discharge from any and all
claims, damages, injuries, or liabilities of any type of nature arising from or associated with any property damage,
death or personal injury our child or we may sustain all the following persons or entities: Grace Church, any of its
affiliated programs or ministries, and its Senior and Associate Pastors, Elders, employees, volunteers,
representatives, subcontractors, and agents: B) We agree not to sue any of the persons or entities identified in
clause A above for any of the claims, damages, injuries, or liabilities that I have waived, released or discharged
herein except in the case of gross negligence on the part of Grace Church, Grace Church Staff or volunteers and:
C) We indemnify and hold harmless the persons or entities identified in clause A above from any claims, dam
ages, injuries, or liabilities that may be asserted or assessed against any of them arising from or in any way
connected with my child’s actions, failures to act, or participation in any activity. We hereby voluntarily assume
and accept all of the risks of or that could occur in connection with our child participating in any Grace Church
activities. D) We further agree to indemnify and hold harmless the persons and entities identified in clause A
above for any claims, damages, or liabilities assessed against any of them as a result of or related to any
insufficiency of our legal capacity or authority to act for and on behalf of our child in the execution of the Waiver
and Release. The claims, damages, injuries, and liabilities referenced in this document include, without limitation,
reasonable attorney’s fees of the parties I release or indemnify herein.