Medical Form - 2007-2008

Medical Information and Permission Form for all church activities for First Lutheran Church, 1551 South 70th Street, Lincoln NE 68506

To be completed by parent/guardian. After filling in all the necessary
information, print off the pages on your printer and sign it. Then you
can bring it in at the time of the event, or mail it to First Lutheran
Church, 1551 S. 70th, Lincoln, 68506. Or if you submit it, then you will
need to sign it when you bring your child to the event.

On the grade, use 0 for Kindergarten
Grade in Fall 2007*
Name*
Date of Birth*
Address*
City, State, Zip*
Phone Number* ( ) -
Mother's Name
Mother's Address
Mother's Phone No. ( ) -
Mother's Work Phone ( ) -
Mother's Cell Phone ( ) -
Father's Name
Father's Address
Father's Work Phone ( ) -
Father's Home Phone ( ) -
Father's Cell Phone ( ) -
Contact Person if Parents Cannot be Reached*
Address*
Home Phone* ( ) -
Work Phone (if applicable) ( ) -
Cell Phone (if applicable) ( ) -
Date of Last Tetanus Shot*
Allergies
List Any Chronic Medical or Physical Conditions
Medications Taken Regularly (include prescription/over the counter and contact lenses)
Physician's Name*
Physician's Phone Number* ( ) -
Physician's Address*
City, State, Zip*
Health Insurance Company Name*
Name of Insured*
Policy or ID Number*
Additional Comments
Date*
I, who by law may do so, authorize the administration of emergency
medical treatment to s/he who is subject of this form. I understand all
reasonable safety precautions will be taken at all times by First
Lutheran Church and its agents to avoid accident, injury and disease,
and I will therefore not hold first Lutheran Church liable for any accident,
injury or disease incurred by the subject of this form. I understand
that in the event medical intervention is needed every attempt will be made
to contact the person(s) listed on this form.

I authorize First Lutheran staff and volunteers to use photos of my
child on the church web page and in advertisements within the church.

This form shall remain in effect for one year from the date of execution.

Signed___________________________________

Date_____________________________________
Confirmation Code:
Enter the code shown in the box before clicking on submit.

Note: Fields marked by an asterisk (*) are required.