Medical Form Child/Youth Name * First Name Last Name Date of Birth MM DD YYYY Phone Number Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact In case of emergency, please attempt contact FIRST with the following local family member. First Name Last Name Phone Number Address Address 1 Address 2 City State/Province Zip/Postal Code Country Medical Insurance Information * Physician First Name Last Name Physician Phone Number Health History Allergies Dietary Restrictions Chronic Health Conditions Special Concerns and Supportive Care Needed: Medications Dose and Time of Day (if applicable) Reason for Taking Checkbox My youth (grades 7-12) will be responsible for their own medications I wish for adult leadership to administer my youth's medication(required for newborns - grade 6) Signature Please enter your name below. SOUTH CAROLINA MISSION TRIP PARTICIPANTS ONLY Date of Last Tetanus Shot MM DD YYYY I DO or DO NOT give permission for my child to operate power tools under the supervision of a responsible adult leader. I DO I DO NOT Please enter your name below Participant (if 18+) or Parent/Guardian (if under 18). Thank you!