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  • Medical Information

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    faithchurchyouth
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    This document collects general and medical information for youth and adult attendees, including name, address, phone number, height, weight, allergies, dietary needs, medical issues, medications, immunization history, insurance details, primary physician, and emergency contact. The information is gathered to ensure proper medical care and accommodations for attendees.

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    This document collects general and medical information for youth and adult attendees, including name, address, phone number, height, weight, allergies, dietary needs, medical issues, medications, immunization history, insurance details, primary physician, and emergency contact. The information is gathered to ensure proper medical care and accommodations for attendees.

    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
    278 views1 page

    Medical Information

    Uploaded by

    faithchurchyouth
    This document collects general and medical information for youth and adult attendees, including name, address, phone number, height, weight, allergies, dietary needs, medical issues, medications, immunization history, insurance details, primary physician, and emergency contact. The information is gathered to ensure proper medical care and accommodations for attendees.

    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
    of 1

    General Information FOR YOUTH and ADULT ATTENDEES

    Name
    Home Phone (____) _______
    Address
    City State _____ Zip

    Medical Information FOR YOUTH and ADULT ATTENDEES

    Birth Date / / Age______ Male____ Female____


    Height Weight_________

    1. List any allergies


    _____________________________________________
    ______________________________________________________________________________
    2. List any dietary needs
    ____________________________________________________________________________________
    __________________________________________________________________________________
    3. List any medical problems, restrictions and/or special needs
    ____________________________________________________________________________
    _____________________________________________________________________________

    4. List medication(s) currently taking ________________________________


    6. Date of last tetanus shot ____________________
    Health Insurance Company / HMO ______
    ID/Policy # Group # ____________
    Primary Care Physician
    _______________Phone(____)___________________
    Emergency Contact: Name __________________________Phone(____)___________________
    Relationship___________________

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