Saint Luke UMC - Youth Medical Release Form

Youth Information

Youth's First Name

Youth's Last Name

Birthdate

Grade

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Primary Contact

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Youth:

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Cell Phone Number

Home Phone Number

Work Phone Number

Email

Alternate Contact in case of Emergency (this person will be called if the previous primary parent/guardian contact cannot be reached)

First Name

Last Name

Relationship to Youth:

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Cell Phone Number

Home Phone Number

Work Phone Number

Medical Information

Insurance Company:

Insurance Phone Number:

Insurance Policy #

Policy Holder's ID #

Name of Physician:

Physicians' Phone Number:

Physicians' Address:

Apartment, suite, etc.

City

State

Zip/Postal Code

Name of Dentist:

Dentist's Phone Number:

Dentist's Address:

Apartment, suite, etc.

City

State

Zip/Postal Code

Date of Last Tetanus Shot

Please list any Allergies your youth may have:

Please send a copy of your youth's insurance card (front & back) to the email link here:

mailto:jim@saintlukeumc.org?subject=Copy of Youth's Insurance Card (Front & Back)