Youth Ministry at 111 N. Howell St., Owosso, MI 48867 US - St. Paul Youth Ministry Heath History Form

School Year:__________________

Student Name:____________________________________________________________

                                    (Last)                           (First)                           (Middle)

Medical Alert: Please list any known health conditions that your child’s teacher or a health care provider should be aware of. (Examples: allergic reactions to food, drugs, insect bites; asthma, diabetes, epilepsy, ADHD, etc.)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the student regularly take any medication?_________________________________

Family physician:___________________________     Phone:________________________

Hospital Preference, if possible:_____________________________________________

CHECK ONE of the following choices and SIGN:

________        In case of an emergency situation requiring professional care, I request

medical treatment for my child until such a time as I may be contacted.

Insurance Co.___________________________________________________________

            Policy#___________________________       Group#______________________

_______          I request NO medical treatment be given to my child and waive all claims

 for failure to provide these medical services.

SIGNATURE of parent or guardian:__________________________________________

                                                Date:______________________

(Please complete the other side)

PRIMARY EMERGENCY CONTACTS ( in a emergency situation, all attempts will be made to contact one of the persons listed here, as soon as possible.)

Mother___________________________________   Phone (H)____________________

            (Last)                           (First)                                      (W)____________________

                                                                                                (C) ____________________

Father____________________________________  Phone (H)____________________

            (Last)                           (First)                                       (W)____________________

                                                                                                (C) ____________________

OR

Legal Guardian___________________________       Phone (H)____________________

                        (Last)                           (First)                           (W)____________________

                                                                                                (C) ____________________

If the parish staff or the group leader of a field trip is unable to reach me or one of the other PRIMARY EMERGENCY CONTACTS, I hereby authorize contacting my physician or one of the persons listed below to assume temporary care of my child in case of a medical emergency:

Name______________________Phone_________________ Relationship____________

Name______________________Phone_________________ Relationship____________

Name______________________Phone_________________ Relationship____________

SIGNATURE OF PARENT:

__________________________________________            Date:___________________