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Yearly Health Form

- Youth Ministry

Teen yearly health form
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- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- HS Grad Year REQUIRED Please fill out this field. Please enter valid data.
- Sex REQUIRED Please fill out this field.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Teen Email REQUIRED Please fill out this field. Please enter an email address.
- Allergies REQUIRED Please fill out this field. Please enter valid data.
- Do you take prescription medication on a regular basis? REQUIRED Please fill out this field.
- Can you be responsible for taking your own medication? REQUIRED Please fill out this field.
- Physician Name REQUIRED Please fill out this field. Please enter valid data.
- Physician Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Please list any other special needs or health concerns: Please enter valid data.
- Parent/Guardian #1 Name REQUIRED Please fill out this field. Please enter valid data.
- Home Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Parent #1 Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent #1 Email REQUIRED Please fill out this field. Please enter an email address.
- Parent/Guardian #2 Name Please enter valid data.
- Home Address Please enter valid data.
- City Please enter valid data.
  
  State
  
  Zip Please enter a zip code.
- Parent #2 Phone Number Maximum 20 characters Please enter a phone number.
- Parent #2 Email Please enter an email address.
- Emergency Contact Name (In case we are unable to reach Parents/Guardians) REQUIRED Please fill out this field. Please enter valid data.
- Relationship REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Agreements
  
  As the parent or guardian of the aforementioned child, in checking I agree and signing this form, I hereby state that the information included in this form is correct and give permission for my child to participate in the activity described on the reverse side of this form.
  
  I understand that my child will be under the supervision of the St. Simon Youth Ministry volunteers.
  
  I hereby give permission for my child to be transported to and from the activity in a vehicle owned by a parish or agency of the Archdiocese of St. Louis or in a private vehicle driven by an adult at least 21 years old.
  
  I recognize that there are risks inherent in participation in any activity and agree to hold the Archdiocese of St. Louis, its affiliates and its and their employees, volunteers and agents, harmless from any injury to my child or damage to or loss of personal property of my child not caused by the negligence or misconduct of the Archdiocese of St. Louis, its affiliates and its and their employees, volunteers and agents.
  
  In the case of a medical emergency, I understand that every effort will be made to contact me, but in the event that I cannot be reached, I hereby give permission for my child to be evaluated, diagnosed and treated in accordance with standard medical practice by licensed medical personnel.
  
  I hereby give permission to the Archdiocese of St. Louis/St. Simon to use any photographs or video footage taken of me in print, on their website, or Social Media sites for promotional purposes.
  
  I Agree Please select this field.
- Parent Signature REQUIRED Please fill out this field. Please enter valid data.
- Zero tolerance Policy agreement
  I understand that for all Youth Ministry activities there is a zero tolerance policy for the use of any mood altering chemicals (including alcohol and illegal drugs), foul language, threats or any type of abuse and inappropriate physical contact. We agree to follow this policy.
  I Agree Please select this field.
- Participant Signature REQUIRED Please fill out this field. Please enter valid data.
- Parent Signature REQUIRED Please fill out this field. Please enter valid data.
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Yearly Health Form

Agreements

Zero tolerance Policy agreement