Gateway Community Church
Student Medical Information Form
STUDENT INFORMATION
Name: _____________________________
Birthday _________________ Age: ______
Address: ____________________________
____________________________________
School & Grade: ______________________
Home Phone: ________________________
EMERGENCY INFORMATION
First Emergency Contact:
Name: _______________________________
Relation: _____________________________
Home Number: ________________________
Work Number: _________________________
Other Number: _________________________
Second Emergency Contact:
Name: _______________________________
Relation: _____________________________
Home Number: ________________________
Work Number: _________________________
Other Number: _________________________
Student’s Physician: _____________________
Address: ______________________________
______________________________________
Phone Number: _________________________
Family Insurance Company: _______________
Policy Number: _________________________
MEDICAL HISTORY
Immunizations:
 Tetanus  Measles  Mumps
 Polio Booster  Other________________________
Please check the appropriate info:
 Asthma  Diabetes  Heart Trouble
 Bronchitis  Sinusitis  Dizziness
 Hay Fever  Kidney Trouble  Social Disorders
 Stomach Trouble  Other______________________
Allergies (please list):
Foods: ___________________________________
Drugs: ___________________________________
Insect Stings/Bites: _________________________
Plants: ___________________________________
Previous Operations: ________________________
Previous Serious Illnesses: ___________________
Current Medication: _________________________
Special Diet: _______________________________
PERMISSION & RELEASE FORM
I hereby grant permission for my child,
_____________________, to attend off
campus activities sponsored by Gateway
Community Church. I also acknowledge that
Gateway Community Church is not
responsible for injury or loss of personal
belongings on these trips.
In the event that my child becomes ill or
injured while under the church’s
supervision, I authorize the leader or their
designee to take the following steps:
1) Contact the parents of the child IMMEDIATELY
and follow his or her instructions.
2) In the event that neither parent can be
reached, GCC will contact the 2nd emergency
contact and/or the child’s physician and follow
their instructions. In the event that these
contacts cannot be reached, GCC will use their
discretion in contacting a properly licensed
practicing physician.
3) If, in his or her opinion, the child needs
medical or surgical services which require the
parents’ consent and the parents cannot be
reached, I, the parent, hereby authorize,
appoint, and empower the leader or their
designee to furnish on my behalf such written
or oral authorization as may be required.
4) I release the leader or their designee and GCC
and/or agent thereof from any liability which
might arise from the granting of such
authorization, since it is my desire that my
child receive medical attention as soon as
possible.
Signature of Parent or Guardian:
_______________________________
Date: __________________________