HTC Young Adults Master Medical Form

Name

D.O.B.

Mobile

This address will receive a confirmation email

Home Address

In Case of Emergency

Emergency Contact

Relationship

Emergency Contact Number

Medical Form

Must check 1 OR 2 to indicate desired action in the event of an accident or emergency.

Choose one

Option A Option B

Option A

In the event of an accident or other emergency, when I am unable to make a decision, I hereby authorize a representative of Harbor Trinity Church to make such arrangements as he/she considers necessary to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.

Physician's Name

Phone

Health Insurance Provider

Group ID

Option B:

I do not choose the above statement and desire that the following action be taken (write below):

Desired action:

Health History

Allergies

None Drugs Insect Stings Food Other

If any of the above are checked, please explain and include normal treatment of allergic reaction:

If any of the above are checked, please explain and include normal treatment:

Name any dosage of any medication being taken

Date of last tetanus shot

Other restrictions Swimming Food Other Activity

If any of the above are checked, please explain and elaborate:

Waiver of Liability

I do fully and expressly release, indemnify, and hold harmless HARBOR TRINITY CHURCH (HTC), 1230 Baker Street, Costa Mesa, California, its Board, Members, staff, employees, and their assigns from any and all liability for any harm, including, but not limited to, any accident, injury, or death, incurred by my child as a result of his/her participation in any event, including, but not limited to, any athletic, recreational, social, or other activity, sponsored or attended by HTC Youth Ministry.

Signature (type full name to sign)

Date of Signature

Description

We are so glad you are part of our ministry in HTC Young Adults! Also, it is important to us that we have your information for medical care to make sure you're taken care of in the event of any accident or emergency.

Valid for two (2) school years, this form is used to consolidate all our HTC Young Adult's important medical information.

Unless otherwise indicated, this form is valid for events for the current school year and the next for all our annual HTC Young Adults events that you might be part of!

Please accomplish this form and hit 'Submit'.

Thank you!

HTC Young Adults Master Medical Form

Description

Please Fix the Following