Croatan FWB Youth Group ( Young Believers )

General Information FOR YOUTH and ADULT ATTENDEES

Name:_______________________________________
Home Phone: (____) ____________________________
Address______________________________________________________
City_____________________________ State_______________ Zip______________
Medical information FOR YOUTH and ADULT ATTENDEES
Birth Date: ____/_____/_______
Age:______ Male_____
Height_____________ Weight___________________

Female_______

1. List any ALLERGIES:_______________________________

_______________________________________________________________________
_______________________________________________________________________
__
2. List any Dietary Needs:
_______________________________________________________________________
_______________________________________________________________________
__
3. List ANY Medical Problems, Restrictions and/or special needs:
_______________________________________________________________________
_______________________________________________________________________
__
4. List Medication(s) currently taking and dosage:
_______________________________________________________________________
_______________________________________________________________________
__
5. Date of last tetanus shot:________________________________
Medicade: YES / NO
Medicare: YES / NO
Health Insurance Company:________________________________________________
ID/Policy #:______________________________ Group #:_______________________
Primary care Physician:____________________________________________________
Phone:___________________
EMERGENCY CONTACT INFORMATION:
Name:________________________________ Phone:___________________________
Relation:______________________________
Parent or Adult Attendee Signature:___________________________________________
Youth Worker Signature:___________________________________________________