NAYC Youth Medical Form - The Way Boston

Phone number *

Birthdate *

Gender *

Grade *

Parent/Guardian Information

Full Name *

Address *

Phone number *

Email *

Emergency Contact

Name and Phone number

Emergency Contact *

Name and Phone number

Allergy and Medical Information

Daily Medications List

Please list any medications your student needs to take daily. Include instructions for use (i.e. times, amount, etc.)

Allergies, Illness, or Food Restrictions

Other Medical Treatment Needed

Diabetic *

List Any Health Issues

Hospitalization Insurance *

Parental Consent

As the parent and/or legal guardian of the student named in this form, I authorize The Way Church, its agents, employees, and other officers to procure and consent to any medical emergency treatment, including hospital care, to be rendered to my student by or under the supervision of a licensed health care provider. The parent/legal guardian is responsible for any fees or costs. My signature below represents consent and agreement to the matters stated above.

Signature *

By typing your name, you are giving consent

Today's Date *