W.I.N.G.S. Youth Group Health Form
W.I.N.G.S. YOUTH GROUP HEALTH FORM
First Congregational Church of Winter Park
225 South Interlachen Avenue Winter Park, FL 32789
407-647-2416
http://www.fccwp.org
WINGS Youth Group Health Form Submission
* Required
Participant's Full Name (First, M., Last *
Part 1: GENERAL INFORMATION
IS APPLICANT IN GOOD HEALTH AND ABLE TO PARTICIPATE IN ALL USUSAL ACTIVITIES? IF NOT, PLEASE EXPALIN BELOW. *
If no, please explain.
Physician's Name *
Physician's Phone Number *
Date of Last Tetanus Booster *
Please list any allergies. If none, please so state.
Please list any special medical conditions.
Check all of the following that apply:
Medical History
If any of the "History" boxes are checked, please provide an explanation for each.
Will the participant be taking any reqular medications? *
If yes, please provide: name of medciation, dose, time to be administered and reason for medication below.
I give permission for my son/daughter to receive over the counter non-prescription medications (i.e., Tylenol, Aspirin, etc.) *
ARE THERE ANY OTHER CONCERNS ABOUT WHICH WE SHOULD BE AWARE? (Include any physical, intellectual or emotional problems, learning disabilities, or recent changes in family ststus or living arrangements which may affect the poarticipant's experience). If No, please so state. *
Name of Medical Insurance Company
Medical Insurance Policy Number
PART 2: PERSON(S) TO NOTIFY IN CASE OF EMERGENCY
Name of primary emergency contact. *
Street address *
City *
State *
Zip code *
Relationship to participant. *
Please list all emergency contact phone numbers. *
Name of secondary emergency contact.
Street address
City
State
Zip code
Relationship to participant.
Please list all secondary emergency contact phone numbers.
PART 3: IN CASE OF ACCIDENT OR ILLNESS
I hereby give permission to the medical personnel, selected by the FCCWP staff, to provide necessary transportation and secure proper treatment, to order medications, hospitalization, anesthesia, and surgery for:
Name of participant. *
Parent/guardian signature *
Relationship to participant. *
Parent/guardian date of birth (mm/dd/yyyy). *
Parent/guradian Social Security Number (nnn-nn-nnnn) *
Date signed. *
Witness signature. *
Date signed. *