DATE OF BIRTH____________________ AGE_______________ SEX___________________

HOME ADDRESS ______________________________________________________________

PARENT/GUARDIAN___________________________________________________________

HOME PHONE_________________________ WORK PHONE__________________________

IF PARENT OR GUARDIAN CANNOT BE REACHED IN AN EMERGENCY THEN PLEASE NOTIFY:

1.NAME__________________________ ADDRESS__________________________________

HOME PHONE_________________________ WORK PHONE__________________________

2.NAME__________________________ ADDRESS___________________________________

HOME PHONE_________________________ WORK PHONE__________________________

ANY PRE-EXISTING OR PRESENT MEDICAL CONDITIONS:________________________

______________________________________________________________________________

NAME AND DOSAGE OF ANY MEDICATIONS THAT MUST BE TAKEN:______________

______________________________________________________________________________

ANY ALLERGIES?_______________________ TO MEDICATIONS?____________________

HAY FEVER_____ HEART CONDITION_____ DIABETES_____ INSECT STINGS_____

EPILEPSY/NERVOUS DISORDERS_____ ASTHMA_____ PHYSICAL HANDICAP_____

FREQUENT STOMACH UPSETS_____ MAJOR ILLNESS DURING THE PAST YEAR?____

IF ANY OF THE ABOVE CHECKED, PLEASE GIVE DETAILS (I.E. INCLUDE NORMAL TREATMENT FOR ALLERGIC REACTION)________________________________________

______________________________________________________________________________

DATE OF LAST TETANUS SHOT_______________ CONTACT LENSES?_______________

ANY SWIMMING RESTRICTIONS?_______________________________________________

ANY ACTIVITY RESTRICTIONS?________________________________________________

IS THE CHILD UNDER ANY SPECIAL MEDICAL TREATMENT OR DIET THAT NEEDS TO BE CONTINUED?___________________________________________________________

______________________________________________________________________________

IN CASE OF MEDICAL OR SURGICAL EMERGENCY, I HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED BY CHURCH OF THE HOLY SPIRIT OR HIS/HER REPRESENTATIVE TO HOSPITALIZE AND/OR SECURE PROPER MEDICAL TREATMENT FOR MY ABOVE NAMED CHILD. I UNDERSTAND THAT I AM RESPONSIBLE FOR THE COST OF ANY MEDICAL TREATMENTS (INCLUDING SURGERY) RECEIVED BY MY CHILD. I HEREBY RELEASE THE DIRECTORS AND STAFF OF THIS EVENT FROM ALL RESPONSIBILITY FOR SICKNESS OR ACCIDENTS WHICH OCCUR DURING THE EVENT. I UNDERSTAND THAT I WILL BE CONTACTED IMMEDIATELY IN THE CASE OF AN EMERGENCY.

SIGNATURE____________________________________________ DATE_________________

HOME ADDRESS_______________________________________________________________

PHONE__________________

INSURANCE COMPANY________________________________________________________

POLICY #____________________________ INSURANCE CERTIFICATE #_______________