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Horne Memorial UMC Health Form
Youth Name____________________________________ Phone__________________________________________
Address____________________________________ Town/City_________________________Zip______________
Email___________________________Date of Birth__________________T shirt Size________ (adult sizes)
Emergency Contact #1____________________________relationship____________Phone___________________
Emergency Contact #2____________________________relationship____________Phone___________________
Health Insurance Company ______________________Policy No.___________________
Family Physician _____________________________Phone ________________________
Please list any allergies or special needs.
Is there anything else we should know about your child?
In signing this health form, I hereby certify that the above information is correct and give permission for my child to be transported in privately owned vehicles to the Youth Program activity sites and evening activities and for medical and other emergency purposes only and for the release of medical records to an attending physician in case of illness. In case of medication emergency, I understand that every effort will be made to contact the parents or guardians. In the event that I cannot be reached, I hereby give permission to the physician selected to secure proper treatment for my child named herein. I give permission for the adult leaders of Horne Memorial UMC to care for my child in case of an emergency, and I understand that Horne Memorial UMC is not responsible for any expense or liability.
Signature of parent/guardian____________________________Phone Number_____________________________
Date___________________
Signature of Director of Youth Ministries_______________________________
Date____________________
