LUFKIN FIRST UNITED METHODIST CHURCH

THIS FORM MAY BE PHOTOCOPIED WHEN COMPLETED. PRINT CLEARLY. USE BLACK INK.

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Youth’s Full Name                                        Home Phone                           Cell Phone (if applicable)

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Home Address                                                   City                                          Zip

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Email                                                                Grade                                       School

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Social Security                                                 Date of Birth

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Date of Last: Health Exam                             Tetanus Shot                             T.B. Test

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Youth’s Doctor /Clinic                                       Phone

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Father’s Name                                                   Work Phone                           Cell Phone

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Mother's Name                                                 Work Phone                           Cell Phone

 

HEALTH STORY: (CHECK THOSE THAT APPLY)

DISEASES: ____Chicken Pox ____Measles ____German Measles ____T.B.

ALLERGIES: ____Animals ___Food ___Insect stings ___Medicine/drugs ___Plants ___Pollen ____ Other

If any checked please explain: ____________________________________________________________

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SHOT RECORD: _______Hepatitis A ________Hepatitis B ________Tetanus Shot

CHRONIC OR RECURRING ILLNESS:

___Ear infections ___Contact lens wearer ___Heart defect/disease ___Seizures ___Bleeding disorder

___ Asthma ___Diabetes ___Other (specify) __________________________________________________

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IN THE LAST YEAR: (ANSWER YES OR NO)

Complicating medical problems/operations? _______  Serious injury/illness requiring medical care? _________

Please explain: ______________________________________________________________________

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SPECIFIC INSTRUCTIONS CONCERNING MY CHILD'S CARE: _____________________________________

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PRESRIPTION MEDICATION MEDICINES: __________________________________________________

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MEDICATION INSTRUCTIONS: __________________________________________________________

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ADDITIONAL HEALTH INFORMATION: ____________________________________________________

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HOSPITAL INSURANCE INFORMATION: * Please attach photocopy of insurance card

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Name of Carrier Policy Number Group Number

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Insured's Name SS#

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Company Name (if insured through employer)

 

FAMILY MEMBER (S) WHO MAY BE CONTACTED IN CASE OF EMERGENCY TO AUTHORIZE TREATMENTS:

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Name                                        Day Phone                           Evening Phone                           Relationship

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Name                                        Day Phone                           Evening Phone                           Relationship

 

MEDICAL TREATMENT AUTHORIZATION

 

I (we) understand that in the event the child named above is injured while in the care of Lufkin First United Methodist Church and requires the attention of a doctor, the Director of Student Ministries, and/or representatives of Lufkin First United Methodist Church will make every effort to contact us.  If I (we) cannot be reached by telephone at one of the numbers listed above, or if because of an emergency, there is not time or opportunity to make a telephone call, I (we) hereby authorize the Director of Student Ministries, and/or representatives of Lufkin First United Methodist Church to give consent on my (our) behalf for emergency medical treatment.  In the event that it becomes necessary for a representative of FUMC Lufkin to give consent on our behalf they are authorized:

 

1.       To have access to any and all medical and related information and records.

2.       To disclose medical and related information to others.

3.       To employ and discharge medical and related personnel.

4.       To consent or refuse consent to medical care and emergency medical procedures.

5.       To provide appropriate relief from pain.

6.       To arrange for care and lodging in a hospital.

7.       To grant releases to health care professionals or institutions to assure that the wishes of the parent/guardian are fulfilled.

  1. To take immediate physical custody and possession of the child that is the subject of this authorization in the absence of the ability of the parent/guardian to do so, and to provide for the care and physical custody thereof during such absence.

 

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Parent Signature (to be signed before a notary)                                                                Date

 

NOTARIZATION REQUIRED

My signature confirms that the above information is correct to the best of my knowledge and that I am authorized to execute the information form and release.                              The State of Texas County of _________________

 

BEFORE ME, A NOTARY PUBLIC, ON THIS DAY PERSONALLY APPEARED

___________________________________________, TO BE THE PERSON WHOSE NAME IS SUBSCRIBED TO THE FOREGOING INSTRUMENT AND ACKNOWLEDGED TO ME THAT HE/SHE EXECUTED THE SAME FOR THE PURPOSES AND CONSIDERATION THEREIN EXPRESSED.

 

Given under my hand and seal of office this _______ day of ____________________, 200____.

 

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Notary Public, State of Texas