Children's Ministry Health Form

Student Info*
Child's Name Age Birthday MM/DD/YY Grade T-shirt Size (YS-AXXXL)
Parent/Guardian First & Last Name(s)*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Phone*
Emergency Contact (other than parent/guardian listed above)*
First & Last Name Relationship Phone
Insurance Information*
Subscriber Name (Name in whom insurance is listed) Insurance Carrier Group Name (Employer) Member ID Address for claims to be mailed
If possible, please upload images of the front and back of your insurance card.
Allergies/Medical Information/Special Needs
**Please include any medications with dose and timing details that your child will take while participating in this event.
Physician's Info*
Physician Name Physician's Phone # Date of last Tetanus Booster MM/DD/YY
Photography Waiver*
- YES
- NO
FIrst United Methodist Church has permission to use images of my child(ren) in photograph or video format for promotional purposes.
Parent/Guardian will be contacted immediately if medical treatment is necessary. By providing my initials below, I give permission for the counselors of First United Methodist Church of Albany, GA to seek medical treatment by a physician or hospital for the minor child listed above if necessary.*

Save and Continue Later

Child's Name	Age	Birthday MM/DD/YY	Grade	T-shirt Size (YS-AXXXL)

Subscriber Name (Name in whom insurance is listed)	Insurance Carrier	Group Name (Employer)	Member ID	Address for claims to be mailed

Physician Name	Physician's Phone #	Date of last Tetanus Booster MM/DD/YY

Children’s Ministry Health Form