2021-2022 Student Ministry Medical Info & Release Form

2021-2022 Medical Info and Release Form

Electronic Signature
Terms of Acceptance and Electronic Signature*
Please read and check each box to indicate you agree to and understand each statement:
- 1. I am this student's parent/legal guardian.
- 2. I have read and give permission as stated above in the Statement of Release.
- 3. All information provided on this form is true and correct.
- 4. I give my permission to photograph and film my student for CCHVILLE use in the following areas: Website, Printed Brochures and Flyers, Facebook, Events and Programs.
- 5. Entering my name below constitutes a legal signature.
TERMS OF ACCEPTANCE AND ELECTRONIC SIGNATURE*
Please type your First and Last Name in the box below to accept these terms.
Student #1 Information
Student Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Date of Birth*
MM slash DD slash YYYY
Grade Student will be in 2021-2022 School Year*
Name of School Student Attends*
Student Cell Number*
Student Email Address*
Parent/Guardian #1 Name*
First Last
Cell Phone Number*
Work/Secondary Phone Number*
Parent/Guardian Email*
Parent/Guardian #2 Name*
First Last
Cell Phone Number*
Work/Secondary Phone
Parent/Guardian #2 Email
Additional Contacts if Parents/Guardians are not available in an emergency:
Name*
First Last
Cell Phone Number*
Name
First Last
Cell Phone Number
Medical Insurance Information
Name Coverage is Under*
First Middle Last
Insurance Carrier
Policy Number*
ID Number*
Primary Physician's Name*
First Last
Primary Physician's Phone Number*
Copy of Student's Health Insurance Card*
Please scan and attach a copy of this student's health insurance card.
Max. file size: 50 MB.
Medical Information
Date of Last Tetanus Shot
MM slash DD slash YYYY
Please list any allergies this student has (food, drug, outdoor stings, ivy, etc)*
Enter "n/a" if there are none. Please indicate if this student carries an epi-pen.
Please list any medications this student takes.*
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.
Please tell us if there are other restrictions or information to know about this student.*
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 Name
First Last
Student #2's Date of Birth
MM slash DD slash YYYY
Grade Student #2 will be in 2021-2022 School Year
Name of School Student #2 Attends
Student #2's Cell Number
Student #2's Email Address
Student #2 Medical Information
Please complete if you have an additional child in CCH's student ministry.
Student #2's Date of Last Tetanus Shot
MM slash DD slash YYYY
Please list any allergies Student #2 has (food, drug, outdoor stings, ivy, etc)
Enter "n/a" if there are none. Please indicate if this student carries an epi-pen.
Please list any medications Student #2 takes.
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.
Please tell us if there are other restrictions or information to know about Student #2.
Enter "n/a" if there are none.
Does Student #2 have the same insurance information as Student #1?
- Yes
- No
If Student #2 has different insurance information, please list the Policy Holder, Inusrance Company, ID #, Group #
Student #3 Information
Please complete if you have an additional child in CCH's student ministry.
Student #3 Name
First Last
Student #3's Date of Birth
MM slash DD slash YYYY
Grade Student #3 will be in 2021-2022 School Year
Name of School Student #3 Attends
Student #3's Cell Number
Student #3's Email Address
Student #3 Medical Information
Please complete if you have an additional child in CCH's student ministry.
Student #3's Date of Last Tetanus Shot
MM slash DD slash YYYY
Please list any allergies Student #3 has (food, drug, outdoor stings, ivy, etc)
Enter "n/a" if there are none. Please indicate if this student carries an epi-pen.
Please list any medications Student #3 takes.
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.
Please tell us if there are other restrictions or information to know about Student #3.
Enter "n/a" if there are none.
Does Student #3 have the same insurance information as Student #1?
- Yes
- No
If Student #3 has different insurance information, please list the Policy Holder, Inusrance Company, ID #, Group #
Comments
This field is for validation purposes and should be left unchanged.

2021-2022 Student Ministry Medical Info & Release Form

2021-2022 Medical Info and Release Form

Electronic Signature

Student #1 Information

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

Medical Insurance Information

Medical Information

Student #2 Information

Student #2 Medical Information

Student #3 Information

Student #3 Medical Information