STATE YOUTH CONFERENCE HEALTH FORM

First name

Last name

Gender

Address

Age

Birthday

Month

Day

Year

Weight

Height

Name of Health Insurance

Insurance I.D. #

Policy #

Date of last physical exam

Month

Day

Year

Do you have any complicating medical problem(s)?

Special dietary of medication instructions

Phone

Parent(s)/Guardian

Emergency contact (Person to notify if Parent(s)/Guardian can not be reached) Name

Relationship to youth

Phone of contact

BY SUBMITTING THIS FORM, WE THE PARENT(S)/GUARDIAN OF THE AFOREMENTIONED CHILD HEREBY GRANT OUR PERMISSION TO THE ADULT IN CHARGE TO ACT ON OUR BEHALF FOR ANY MEDICAL AND/OR EMERGENCY TREATMENT THAT IS NECESSARY FOR OUR CHILD’S WELL-BEING IN CASE OF SUDDEN ILLNESS OR ACCIDENT SHOULD IT PROVE IMPOSSIBLE TO CONTACT US. WE STIPULATE THAT WE SHOULD BE NOTIFIED WITH ALL DUE SPEED OF CARE AND/OR TREATMENT RENDERED.