CYIA Medical Form 2025
June - July 2025 | Please fill out this form and click submit.
Personal Information
Name
*
Gender
*
Please select one option.
Male
Female
Select Option
Male
Female
Parent/Guardian Name
*
Parent Phone
*
Health Insurance Company
*
Insured Parent's Name and Work Phone Number
*
Policy Number
Family Doctor Name
Dr. Office phone
*
Dr. Office Address
*
Medical History
Any eyeware needed
*
Please select one option.
Glasses
Contacts
none
Allergies to Medications
*
Other Allergies
*
Approx date of last Tetanus Shot
Check any that apply
Please select all that apply.
Earaches
Asthma
Hyperactivity
Insomnia
Headaches
Sleep-walking
Homesickness
Nervousness
Epileptic convulsions
Bedwetting
Stomach aches
Other
Illness or Accidents: date and status:
Medications (please list or write "none")
*
In addition to prescribed medications, my child has my permission to receive the following over-the-counter drugs:
*
List health or other conditions that would limit child's participation in CEF activities:
*
I hereby release Child Evangelism Fellowship of Lone Star Prairie, its staff, board members, and agents from responsibility & liability for any injury or illness that my child may sustain during the above-mentioned CEF program: CYIA. I hereby give permission for my child to receive medical treatment in the event of an emergency. I expect to be contacted as soon as possible.
*
On electronic forms, your typed signature carries the same weight as your written signature.
Parent/Guardian Signature
*
Email
*
This address will receive a confirmation email
Submit
Description
June - July 2025
Please fill out this form and click submit.
×
Please Fix the Following