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St. Luke’s Child Enrichment Center 9 119 North 33rd Street, Billings, MT 59101 9 406.252.4777

MEDICAL FORM Participant _______________________________________________________________ Sex _____________ First



Birthdate ________/__________/__________

Home Phone _______________________

Family Physician ________________________________________ Phone ____________________________ Father’s Name _________________________________________ Work phone ________________________ Mother’s Name ________________________________________

Work phone ________________________

Medical History ************************************************************************* 1. 2. 3. 4.

Is your child under medical care? Yes no Is your child taking any medication? If so, what kind? For what?______________________________ When was your child’s last physical exam? ____ /____ / ____ Does your child have any heart problems, breathing problems, allergies, or other medical/physical problems our instructors should be aware of? Please explain:

5. Date of the last Tetanus booster? ____ / ____ / ____ 6. Surgical Operations/year? ________________________________________________________________ 7. Injuries or Accidents: ____________________________________________________________________ 8. In Case of Emergency Contact (If you cannot be reached):

1st choice: ____________________________________________ Phone: ___________________________

2nd choice: _____________________________________________ Phone: ___________________________

As parent and/or guardian I do herewith authorize the treatment by qualified and licensed medical doctor, of the following minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. Parent/ Legal Guardian Signature __________________________________________ Date _________________ Address ___________________________________________________


State ____________ Zip _____________ Date or dates when release is intended: _______________________

Medical Form  

St. Luke's Child Enrichment Center Medical Form

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