Health Form

* Indicates required field

Name *

First

Last

Date of Birth *

Insurance information (Carrier and Policy Number) *

Emergency Contact *

First

Last

Emergency Contact phone *

List any frequent or chronic illness *

Dietary restrictions *

Medications (be sure to bring extras *

Allergies and type of reaction *

Date of last tetanus shot *

Any other information the leaders should know? *

By signing below I give permission for the leadership of the East Association Churches to seek medical attention for me if I am unable to make sure a decision. *

Today's Date *

If team member is under 18, please have the parent or guardian sign below to authorize leaders to seek medical attention if necessary. *

Submit