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    Teens Encounter Christ Medical Form: DD/ MM/ Yy

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    shawnbranch
    This document is a medical form for Teens Encounter Christ that collects information about a participant's medical history and emergency contacts. It requests the participant's name, age, birthdate, gender, address, phone number, physician information, and medicare number. For minors it requires parent/guardian names and phone numbers. For adults it asks for an emergency contact. It then has checkboxes to indicate any chronic conditions, allergies, medications, or dietary concerns. The parent or participant signs to authorize the CORE team to administer first aid and transport the participant for medical assistance if needed.

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    Teens Encounter Christ Medical Form: DD/ MM/ Yy

    Uploaded by

    shawnbranch
    80 views3 pages
    This document is a medical form for Teens Encounter Christ that collects information about a participant's medical history and emergency contacts. It requests the participant's name, age, birthdate, gender, address, phone number, physician information, and medicare number. For minors it requires parent/guardian names and phone numbers. For adults it asks for an emergency contact. It then has checkboxes to indicate any chronic conditions, allergies, medications, or dietary concerns. The parent or participant signs to authorize the CORE team to administer first aid and transport the participant for medical assistance if needed.

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    Medical Form

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    This document is a medical form for Teens Encounter Christ that collects information about a participant's medical history and emergency contacts. It requests the participant's name, age, birthdate, gender, address, phone number, physician information, and medicare number. For minors it requires parent/guardian names and phone numbers. For adults it asks for an emergency contact. It then has checkboxes to indicate any chronic conditions, allergies, medications, or dietary concerns. The parent or participant signs to authorize the CORE team to administer first aid and transport the participant for medical assistance if needed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    80 views3 pages

    Teens Encounter Christ Medical Form: DD/ MM/ Yy

    Uploaded by

    shawnbranch
    This document is a medical form for Teens Encounter Christ that collects information about a participant's medical history and emergency contacts. It requests the participant's name, age, birthdate, gender, address, phone number, physician information, and medicare number. For minors it requires parent/guardian names and phone numbers. For adults it asks for an emergency contact. It then has checkboxes to indicate any chronic conditions, allergies, medications, or dietary concerns. The parent or participant signs to authorize the CORE team to administer first aid and transport the participant for medical assistance if needed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    Teens Encounter Christ

    Medical Form

    Name: _____________________________________________________________
     
    Age: _____  Birth Date: ___/___/___  Gender _____ 
    DD/ MM/ YY 
       

    Home Address: _______________________________________________ 

    Phone: _______________________ Postal Code: ___________________ 

    Family Physician: _______________________ Phone: _______________ 

    Medicare Number: ___________________ 

    If under 18, please fill out the following information: 

    Father/Guardian Name: ____________________ Phone: ______________ 

    Mother/Guardian Name: _____________________ Phone:_____________ 

    If over 18, please give us an emergency contact name and number 

    Name: _______________________________ Phone: ________________ 

    General Information 

    Please complete the section below by checking the condition(s) which apply. 
    Strict confidence will be kept. 

    1. Chronic Conditions: 
    Yes No                      Further Explanation or Treatment 
    ___ ___ Allergies ____________________________________________ 
    ___ ___ Asthma _____________________________________________ 
    ___ ___ Hayfever ____________________________________________ 
    ___ ___ Diabetes_____________________________________________ 
    ___ ___ Epilepsy _____________________________________________ 
    ___ ___ Heart _______________________________________________ 
    ___ ___ Sight _______________________________________________ 
    ___ ___ Contact lenses ________________________________________ 
    ___ ___ Hearing _____________________________________________ 
    ___ ___ Headaches ___________________________________________ 
    ___ ___ Hyperactivity _________________________________________ 
    ___ ___ Other (specify) ________________________________________
    2. Medication Policy is that the team member will hold and administer their own 
    medication. 

    Will you be on medication during the weekend?     Yes ____ No ____ 

    If yes, please specify particulars: 
    First Medication _______________________________ 
    Reason _________________________________________ 
    Instructions _____________________________________ 

    Second medication ___________________________________ 
    Reason: _______________________________________ 
    Instructions _____________________________________ 

    Do you have food allergies or concerns (i.e. vegetarian, etc.) 
    ____________________________________________________________ 
    ____________________________________________________________ 

    Myself or the parent(s) or guardian(s) of the above­named person, I/we hereby state 
    that the information stated above is correct and true to the best of my/our knowledge. 

    I/we authorize the Members of the CORE Team to administer first aid and to secure 
    such medical advice and services as deemed necessary for the health and safety of the 
    above­named person.

    I/we further authorize the above­named person to be transported in a 
    private vehicle if necessary to secure such medical assistance. 
    Signature of Parent(s) or Guardian(s) or Team Member if 18 years or older 

    ________________________________   Date: _____________________________

    Please return completed form to the CORE Team.

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