Velocity Health Form

_____________________________
Church your child is with
Student Health Form

______________________________________Age _______ Sex ________ Birth date ________________
Last Name
First Name
MI
______________________________________
Address
___________________________________________
City
State
Zip
______________________________________
Youth Leader
Immunization Record
Please indicate date of immunizations of the following
Tetanus/Diphtheria:
DPT/TD
_________
_________
_________
_________
_________
Polio:
OPV/IPV
________
________
________
________
Measles:
Rubella:
Hepatitis B:
________
________
________
________
________
________
________
Health History:
Allergies
Check if these apply to your child:
________Rheumatic Fever
Aspirin ________
________Asthma
Penicillin______
________Epilepsy
Other Drugs _________________________
________Diabetes
Foods ______________________________
________Behavior (please describe- e.g. nosebleeds, bedwetting, headaches, sleepwalking, etc.)
______________________________________________________________________________________
Precautions to be observed: _______________________________________________________________
Operations or injuries: ___________________________________________________________________
Medications:
Drug
__________
__________
__________
Purpose
__________
__________
__________
Dosage
__________
__________
__________
In the event my child should have minor complaints of uncomplicated/simple headache, stuffy nose, cough,
or diarrhea, I give permission for the registered nurse to administer over the counter medications to help
alleviate the symptoms.
Please initial one:
________ Yes, I give permission for the nurse to administer
over the counter medications.
________ No, I do not give permission for the nurse to
administer over the counter medications.
I hereby certify that the above health record is, as of this date, accurate and complete.
________________________________
__________________
Signature of Parent or Guardian
Date Completed
Medical Care Release

We (I) authorize an adult, in whose care (name of child)___________ has been entrusted, to
consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and
hospital care, to be rendered to the minor under the general or specific supervision and on the advice of any
physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a
licensed hospital or medical center, whether such diagnosis or treatment is rendered at the office of said
physician and said hospital or medical center.
The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection
with such medical and dental services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for our/my child to return home due to medical reasons or otherwise, the
undersigned shall assume all transportation costs.
Participant Signature________________________________________________Date_________
Parent/Guardian Signature___________________________________________Date_________
Phone Number____________________Birth Date__________________________Age________
Name of Parent(s) or Legal Guardians(s)____________________________________________
Secondary Phone Number (in case of emergency)_____________________________________
Insurance Company and Number __________________________________________________
Please attach a photocopy of your current insurance card. (Front and back)
Liability Agreement:
In consideration for permission and support by Evangelical Youth Fellowship and all participating
churches for my child to participate in and receive accommodation for Velocity 2011, June 25-30, 2011,
I, the undersigned, for myself, my heirs, executors, administrators and assigns do hereby release, hold
harmless, indemnify, waive and discharge Evangelical Youth Fellowship and all participating churches,
staff members, and their agents (whether paid or volunteer) from and against any and all claims, demands,
actions, or causes of action arising from any injuries or damages my child may suffer or sustain by my
participation in Velocity 2011. Furthermore, in full recognition and appreciation of the potential dangers
and hazards inherent in travel to and participation in Velocity 2011, I do hereby agree to assume all the
risks and responsibilities surrounding my childs participation in this activity or any other activities
undertaken in addition thereto.
Signature of Parent(s)/ Guardian____________________________________________________________
Photo Release
I certify that photographs or videotape pictures of my child participating in Velocity 2011
programs may be reproduced and utilized in promotional materials for the conference.
The undersigned acknowledges having read and understood to foregoing informed consent form.
In witness whereof, I have caused this release to be executed this ____ day of _______, 2011.
Participants Signature___________________________________________________________
Participants Printed Name________________________________________________________
Parent/Guardian Signature________________________________________________________
Address ______________________________________________________________________
Phone: Work (
)___________________ Home (
)____________________________

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_____________________________

Church your child is with

Student Health Form

Check if these apply to your child:

Signature of Parent or Guardian

Medical Care Release

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