Child Medical Information and Permission Form

Medical Information & Permission Form

As a part of Assembly Mennonite Church’s commitment to the safety and well being of our children we ask that this form be filled out by the child’s parent/guardian for our own confidential records to ensure that we are aware of any special needs and are able and authorized to care for them in case of an emergency.

Personal Information for Child
Name of Child
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Date of Birth
MM slash DD slash YYYY
School
Grade
Health Care
Please list any special Health Care needs below. Be sure to include food/drug allergies, medical conditions as well as any other information that would be helpful in an emergency.
Vaccination Status
Please indicate whether or not this child is vaccinated against COVID-19.
Emergency Contact Information
Names of Parent(s)/Guardian(s)
Phone
Secondary Contact Name and Phone number
Is this person authorized to guide medical care?
Check one
- Yes
- No
Do you give permission for Assembly to share your child's contact information with Mennonite Education Agency in their census?
Check one
- Yes
- No

Child Medical Information and Permission Form

Medical Information & Permission Form

Personal Information for Child

Emergency Contact Information