Student Ministry Medical FormStep 1 of 520%Student InformationStudent Name* First Last Birthday* MM slash DD slash YYYY High School Graduation Year*2020202120222023202420252026Mother's Name First Last Work PhoneCell PhoneFather's Name First Last Work PhoneCell PhoneEmergency Contact (if parent is unavailable)Name First Last PhoneRelationshipFamily DoctorPhoneFamily DentistPhoneFamily’s Medical Insurance CompanyEmployer’s group medical insurance account numberConfidential Health HistoryHas he or she had (please mark yes or no to each):Allergies?* Yes NoHeart Ailments?* Yes NoDiabetes?* Yes NoSeizures/fainting spells?* Yes NoAsthma?* Yes NoAny significant injury or operation?* Yes NoTaking any medication?* Yes NoAllergic to Penicillin or other medication?* Yes NoAny other known aliment we should know about?* Yes No**Please explain fully if you answered yes to any of the above questions and/or any additional information that would be helpful for leaders to know when ministering to your child?Date of last Tetanus shotCPC Student Health Agreement: CPC Leaders reserve the right to require proper use of face mask/ face coverings at all events on CPC property (indoor and outdoor). CPC Leaders reserve the right to maintain social distancing standards and direct students towards safe in-person interactions. Students that do not respond to leadership guidelines and direction may be asked to leave and wait in a designated area until parents can pick up. Our community agrees to act with caution and care for the health and safety of others while respecting all community guidelines to reduce the spread of COVID-19. Parent and student initials:*Please check box is if you allow us to use any photos we take of your child on our website and social media platforms. YesPermission for medical treatmentIn the event my son or daughter becomes ill or sustains injury while in the care of or in the supervision of the Centreville Presbyterian Church youth workers, they are given permission to administer first aid for my son or daughter’s relief. Consent is also given to admit him or her to any hospital facility and for all medical, surgical, diagnostic, and hospital procedures or treatment as may be performed or prescribed, including the administration of such drugs or medications, by a physician for him or her when such treatment is deemed immediately necessary or advisable to safeguard my son or daughter and it is not advisable or practical to return him or her to me or receive my instruction for his or her care. I waive my right to informed consent for said treatment.Consent* By checking this box and typing my name below, I am electronically signing the registration.Electronic Signature*Parent / Guardian, please type your first and last name.Date* MM slash DD slash YYYY Δ
