Fillable 231 W. Hancock St GC Youth Programs Medical (Georgia College)

Fill Online, Printable, Fillable, Blank 231 W. Hancock St GC Youth Programs Medical (Georgia College) Form

Use Fill to complete blank online GEORGIA COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

231 W. Hancock St GC Youth Programs Medical (Georgia College)

On average this form takes 13 minutes to complete

The 231 W. Hancock St GC Youth Programs Medical (Georgia College) form is 2 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 46 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Georgia College

BROWSE GEORGIA COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Youth Medical Information Form
Approved: OLA; Revised 3/2019; Effective 4/1/2019
Page 1 of 2
231 W. Hancock St
Milledgeville, GA 31061-0490
Phone Number: (____) ____-_____
Fax Number: (____) ____-_____
GC Youth Programs
Medical Information Form
I.
Personal Information (please print) Today’s Date: _____ / _____ / _____
Child’s Name: _______________________________________ Age: _______ Weight: _______ Height: __________
Address: ___________________________________________ City: ____________________ State: ______
Parent/Guardian Name: ____________________________________________________________________________
Home Phone: ________________________ Cell Phone: _____________________ Work Phone: _________________
II. Emergency Contact 1
Name of Contact: __________________________________________ Relationship: ___________________
Address: ___________________________ City: ______________ State: ______ Phone: ________________
Emergency Contact 2
Name of Contact: __________________________________________ Relationship: ___________________
Address: ___________________________ City: ______________ State: ______ Phone: ________________
III. Physician/Insurance Information
Family Physician: ____________________________________________________ Phone: ______________________
Primary Insurance Provider: ___________________ Policy Number: ________________ Phone: ________________
Secondary Insurance Provider: _________________ Policy Number: _________________ Phone: ________________
IV. Medical Information
Please list any current medical concerns or medical history we need to know about from your child:
Please list any allergies your child has (Ex. Medications, bug stings, food, latex, etc.):
Youth Medical Information Form
Approved: OLA; Revised 3/2019; Effective 4/1/2019
Page 2 of 2
Does your child require any accommodations to safely participate in the program? If so, please explain:
If your child takes prescription medication, you are required to meet with the Program Administrator
to discuss the expectations of the program staff. Initial in the box to the left if you will be requesting a
meeting. Please schedule your meeting as soon as possible.
Parent or Guardian Name: __________________________________________ Date: ___________________________
Signature of Parent or Guardian: _____________________________________
Initials
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

231 W. Hancock St GC Youth Programs Medical (Georgia College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document