2018-2019 Student Ministry Medical Info & Release Form

 In Family Ministry

2018-2019 Medical Info and Release Form

  • Electronic Signature

  • Please read and check each box to indicate you agree to and understand each statement:
  • Please type your First and Last Name in the box below to accept these terms.
  • Student #1 Information

  • Additional Contacts if Parents/Guardians are not available in an emergency:

  • Medical Insurance Information

  • Please scan and attach a copy of this student's health insurance card.
  • Medical Information

  • Enter "n/a" if there are none. Please indicate if this student carries an epi-pen.
  • Enter "n/a" if there are none. Please indicate if student will bring medication with them and if a leader needs to administer it or if the student can do so on their own.
  • Enter "n/a" if there are none.
  • Student #2 Information

    Please complete if you have an additional child in CCH's student ministry.
  • Student #2 Medical Information

    Please complete if you have an additional child in CCH's student ministry.
  • Enter "n/a" if there are none. Please indicate if this student carries an epi-pen.
  • Enter "n/a" if there are none. Please indicate if student will bring medication with them and if a leader needs to administer it or if the student can do so on their own.
  • Enter "n/a" if there are none.
  • Student #3 Information

    Please complete if you have an additional child in CCH's student ministry.
  • Student #3 Medical Information

    Please complete if you have an additional child in CCH's student ministry.
  • Enter "n/a" if there are none. Please indicate if this student carries an epi-pen.
  • Enter "n/a" if there are none. Please indicate if student will bring medication with them and if a leader needs to administer it or if the student can do so on their own.
  • Enter "n/a" if there are none.
  • This field is for validation purposes and should be left unchanged.
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