For Office Use Only: MS __ / BGC___

Highland Park United Methodist Youth Ministry

Emergency Medical Information

Personal Information

Participant’s Name: ______Date of Birth M/D/Y ______/______/______

Home Address: ______Home Phone: (______)______

City/State/ Zip: ______Social Security #: ______-______-______

Parent/Guardian Name(s): ______

Mom’s Work #: (______)______Dad’s Work #: (______)______

Emergency / alternate Contact Information

In Case Of EMERGENCY (If Parent Can’t Be Reached) CALL: ______

Day Phone Number: ______Night Phone #: ______

Relationship: ______

Medical Information

Any current medical conditions or problems? ______

______

Any allergies to Medications or Foods? ______

Taking any prescribed medication? ______(IF yes, please fill out information below.)

Name / Dosage / Time of Day / Side Effects / Special Instructions
Ex., Medication XYZ / 25 mg / Morning / With food / Sun burns easily

Does your child take prescription medication during the school year to attend school? ______

Past medical history/injuries we should be aware of: ______

______

Date of last Tetanus shot: ______

Name of Physician: ______Phone #: ______

Name of Dentist: ______Phone #: ______

Insurance Information

Please provide a copy of this information as well as written information below:(New this year.)

Group Or Family Hospitalization Insurance Company:______

Insurance Company's Address: ______

Agent's Name:______Phone #:______

Group #: ______Policy #: ______

Insured’s Social Security #: ______-______-______Insured’s Date of Birth ______/______/______

In Case Of EMERGENCY (If Parent Can’t Be Reached) CALL: ______

Day Phone Number: ______Night Phone #: ______

Please fill out both sides of the form & submit the copies of your insurance card. Page - 1

For Office Use Only: MS __ / BGC___

Waiver of Responsibility

Activity: Spring Day Retreat: Sky Ranch, Sat., April 23, 2015 Time: 7:30 a.m. to 9:00 p.m.

I understand that in the event of medical intervention is needed, every attempt will be made to contact the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give permission to the physician or dentist selected by the activity leader to secure medical treatment and / or to order an injection, anesthesia, or surgery for my child as deemed medically necessary.

I understand that my health insurance coverage for my child will provide primary coverage in the event of medical treatment of intervention is needed.

I agree to allow the identified student to participate in the activity identified above and understand all reasonable safety precautions will be taken at all time by Highland Park United Methodist Church and its’ agents. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Highland Park United Methodist Church, its’ leaders, employees and or volunteer staff liable for any damages, losses, diseases, or injuries incurred as a result of the student’s participation in this activity.

Parent / Guardian Signature: ______

Date: ______

Please return in person, scanned, or emailed to: or by mail to: HPUMC c/o confirmation at 3300 Mockingbird Lane, Dallas, TX 75205 by Friday, April 15, 2016.

Please fill out both sides of the form & submit the copies of your insurance card. Page - 1