EmailMe Form - Bethel Registration/Medical Form

Participant's Name *

First Last

This form is being submitted for the following activity and/or group(s):
(check all that apply) *

School grade or Preschool Class (as of Sept 2017) *

Gender *

Male

Female

Participant's Birth Date *

MM / DD / YYYY

Participant's Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Parent/Guardian Name *

First Last

Parent/Guardian Email

Phone *

### - ### - ####

Cell Phone

### - ### - ####

Parent/Guardian Name

First Last

Parent/Guardian Email

Phone

### - ### - ####

Cell Phone

### - ### - ####

Participant Medical Information

The following information is required for use in case of medical emergency only.

Physician: *

Physician Phone # *

### - ### - ####

Dentist:

Dentist Phone #

### - ### - ####

Eye Doctor:

Eye Doctor Phone #

### - ### - ####

Other:

Other Phone #

### - ### - ####

Participant's current medical condition:

List any prescription and non-prescription medications currently being taken by participant:

List any allergies or drug sensitivities: *

Name of Health Insurance Carrier: *

Insurance Group #: *

Has the participant ever had one of the following?

Disease or disorder of the blood? (explain if yes)

Any physical defect or deformity? (explain if yes)

Any vision or hearing disorders? (explain if yes)

Any contagious disorders?
(explain if yes)

Has the participant been treated by a physician, been disabled or hospitalized during the past year?
(explain if yes)

Has the participant had or been advised to have a surgical operation within the last five years?
(explain if yes)

Date of last physical

MM / DD / YYYY

Date of last tetnus shot

MM / DD / YYYY

Family History:
List any important medical problems within the family:

List any other special medical information not listed above:

Additional Information

Publicity Permission:

Please indicate if you would allow pictures of this participant to be used for Bethel publicity purposes on our website, local newspapers, etc. *

Yes, I allow pictures to be used for publicity

No, I DO NOT allow pictures to be used for publicity

Sunday School Help:

May we add the parent/guardian name to our Sunday School Substitute Teacher list? *

Yes

No

Name of person completing this form: *

First Last

Date Completed: *

MM / DD / YYYY

Signature of person completing this form: *

Clear

Please sign using either your mouse or your finger/stylus on a touch screen.