Winton Rd.

1st Church of God

6200 Winton Road
Fairfield, OH 45014
513.829.0924

Emergency Medical Form

Name ___________________________________________________________________________
Gender _______________ Age _____________ Birthdate _____/_____/______
In case of emergency, notify:
Name ________________________________________________________________________________
Phone ____________________________________ Phone 2 ___________________________________
Address ___________________________________________________ Relationship _______________
Family Physician:
Name _______________________________________________ Phone __________________________
Address ______________________________________________ City, State, Zip __________________
Insurance Information:
Provider: ________________________________________ Policy No. ___________________________
Address ______________________________________________ City, State, Zip __________________
Policy Holder _________________________________________ Type of plan: group individual
Allergies/Other Info:
Penicillin Insect Bites Hay Fever Poison Ivy Other: _____________________________
Date of last Tetanus shot: __________________
Is the participant on any prescribed drugs/medication: yes no
If yes, please explain: ___________________________________________________________________
Additional Information:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

I,
, parent/guardian of
do hereby request that
the above named child be permitted to attend youth activities/events. I agree and consent
to having the leaders/counselors, under whose auspices the program is conducted, and any
other worker in the program approved as parent to secure any emergency medical care or
treatment that may be necessary for my child during the entire outing, including the trip to
and from their destination. I further assume all responsibility for the decisions so made, and
the emergency care or treatment so secured for my child.

_X________________________________________________________
Signature of parent or guardian (if participant is under 18)
OR Signature of participant (over 18)

_____________________________
Date