Youth Medical Information Form
Approved: OLA; Revised 3/2019; Effective 4/1/2019
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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
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signature
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