NLHSA Medical Form

indicates a required answer

NLHSA Medical Form

Important! Agreement to this online form will serve as your "digital signature" so please read carefully before agreeing at the bottom of the page.

1. *	Family Name:

Contact Person in Case of non-medical emergency (when you are unavailable).

2. *	Name:

3. *	Telephone Number:

The following licensed physician is authorized to give emergency medical care to my children.

4. *	Physician's Name:

5. *	Telephone:

6. *	Address:

In the event this physician cannot be reached, I hereby authorize any necessary emergency medical care to be administered to my children.

7. *	Hospital Preference:

8. *	Telephone:

9. *	Name of Insurance Company/Medical Sharing Plan

10. *	Contract Number:

11. *	Group Number:

For questions #12-15, if these questions do not pertain to you, please write N/A.

12. *	Please list any life threatening food allergies or medical conditions that we need to know about to keep your child safe. For example: anaphylactic reaction to peanuts.

13. *	Please list any non-life threatening food allergies/sensitivities for each child.

14. *	Please list any pertinent medical conditions, medications and allergies (non-food) for each child.

15. *	If you have a special needs child, please list any information that would be helpful to the teachers and monitors on how to work with and care for your child.

In the event that I'm unavailable, any NLHSA Board Member has permission to call an ambulance to transport my child(ren) to the nearest medical facility for emergency care. I will assume financial responsibility for any expenses incurred.

16. *

Mother's Agreement:

I agree

I do not agree

17. *

Father's Agreement:

I agree

I do not agree

18. *	Date Signed:

“Skies Above: Proclaiming God's Handiwork"

Psalms 19:1-2 - The heavens declare the glory of God; the skies proclaim the works of his hands. Day after day they pour forth speech; night after night they reveal knowledge.

NLHSA Medical Form