STATE STREET UNITED METHODIST CHURCH
1101 State Street Bowling Green, KY 42101 (270) 842-8171
HEALTH FORM
Name of Youth___________________________________________________________
LAST FIRST MIDDLE
Date of Birth_________Sex_________________Age___________________
Parent/Guardian_______________________________________Home Phone___________ Work Phone___________
Home Address____________________________________________________________
Work Address____________________________________________________________
If not available in an emergency, notify:
Name_________________________________Relationship_____________________
LAST FIRST
Address___________________________________Phone(H)___________________
_____________________________ ___________________
Child’s Physician_________________________________________________________
LAST FIRST
Home Phone______________________Office Home_____________________________
Address_________________________________________________________________
Hospital_________________________________________________________________
Name and Address
The Above Youth Is_____Is Not_____Covered By Medical Insurance.
INSURANCE COVERAGE: (If applicable)
Insurance Company__________________________________Phone ( )____________
Name of Insured__________________________________________________________
Policy #_____________________________I.D.#________________________________
The above youth carries an insurance card. Y / N (circle one)
Adults in charge may administer: ______Aspirin _____Tylenol ____Advil
Special Requirements or limitations___________________________________________
_______________________________________________________________________
Health History
(Check, give appropriate dates [if applicable] and explain below table [if necessary])
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Bleeding/Clotting Disorders
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German Measles
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Bee/Insect Stings
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Convulsions
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Chicken Pox
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Hay Fever
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Diabetes
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Measles
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Poison Ivy, etc.
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Frequent Ear Infections
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Mononucleosis
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Asthma (treatment procedures below)
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Heart Defect/
Heart Disease
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Mumps
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Date of Last Tetanus Shot
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Hypertension
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Blood Type
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Allergies
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Details of above:________________________________________________________________
______________________________________________________________________________
Allergies & Treatment (especially to medicines):_______________________________________
______________________________________________________________________________
List past operations or serious injuries within last two years:______________________________
______________________________________________________________________________
List any dietary modifications or food allergies:________________________________________
______________________________________________________________________________
List current medications being taken by youth (send with instructions):_____________________
______________________________________________________________________________
I hereby give permission to the physician selected by the adults in charge of the State Street UMYF activity to order X-rays, routine tests, and treatment for the health of
__________________________, and in the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by the adults in charge to hospitalize, secure proper treatment for, and to order injections and/or anesthesia and/or surgery for my child as named above.
Parent/Guardian Signature:___________________________Date___________________
State of: ________________
County of: ________________
On this _____ day of ___________________ before me appeared_________________________ who is personally known to me or who has produced ___________________________________
as identification, and who acknowledge the execution of the foregoing instrument as his/her free act of deed, and did not take an oath.
___________________________________ ____________________________________
Signature of Notary Public Name of Notary, printed or stamped
My Commission Expires:___________________________________
For State Street United Methodist Church Office Use Only
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2008
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2009
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2010
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2011
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2012
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2013
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