Health History/Emergency Contact Record

Please fill out this form completely. One form must be completed per child. You will not need to complete this form for each event/program your child participates in, but you must fill out a new form if there are any updates or changes.
Child Information
 
 
 
 
 
 
 
Parent Information
 
 
 
 
 
 
 
 
Emergency Contact
Please list an individual other than parent, who can be reached in case of an emergency. 
 
 
 
Name of Family Physician and Clinic
 
 
 
 
 
Parent/Guardian Authorization
In the event that my child needs medical attention while participating in events at Grace Lutheran Church, I authorize the adult in charge to see that my child receives reasonable first aid and to transport my child to a health care facility for emergency services, as needed.
 
 

Description

Please fill out this form completely. One form must be completed per child. You will not need to complete this form for each event/program your child participates in, but you must fill out a new form if there are any updates or changes.