Children’s Ministry Health Form

Children's Ministry Health Form

  • Child's NameAgeBirthday MM/DD/YYGradeT-shirt Size (YS-AXXXL) 
  • First & Last NameRelationshipPhone
  • Subscriber Name (Name in whom insurance is listed)Insurance CarrierGroup Name (Employer)Member IDAddress for claims to be mailed 
  • **Please include any medications with dose and timing details that your child will take while participating in this event.
  • Physician NamePhysician's Phone #Date of last Tetanus Booster MM/DD/YY 
    FIrst United Methodist Church has permission to use images of my child(ren) in photograph or video format for promotional purposes.