Student Medical 2025-2026

Please complete this form once per student per school year.

Your name *

Email address *

Student's Personal Contact information

Please complete the Student's contact information below. Student's personal cell phone number is optional. Parent/guardian contact information is collected later on the form.

Student's Name *

Address (Please enter House/Street, City, State, Zip) *

Birthdate *

School 2025-2026 *

Grade 2025-2026 *

Student's Cell number (optional)

Medical Concerns and/or medications taken regularly:

Parent/Guardian 1 Contact Information and Cell Phone Number

Name (First and Last) *

Parent/Guardian 1 Cell Phone Number *

Is Parent/Guardian 1's address the same as the student's primary address above? *

Parent/Guardian 1 Email Address *

Student Ministry Team will use this address when sending communications related to Middle and High School programs.

Do you have a home land line (not cell phone) for Parent/Guardian 1 you would like to add? *

Additional Parent/Guardian Contact Information

Parent 2 Contact Information and Cell Phone Number

Name (First and Last)

Parent/Guardian 2 Cell Phone Number

Is Parent/Guardian 2's address the same as the student's primary address above?

Parent/Guardian 2 Email Address

Student Ministry Team will use this address when sending communications related to Middle and High School programs.

Emergency Contact (Other than Parent/Guardian)

Emergency Contact Name (First and Last) *

Emergency Contact's Cell Phone Number *

What is the emergency contact's relationship to the student? *

Relative, Family, Friend, Other

Insurance Information

In the event of an emergency and the parent(s) are unavailable

Insurance Company *

Policy Number *

Insurance Company Phone Number *

Name of Policy Holder *

Relationship of policy holder to student *

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