AWANA Medical Consent Form Child's Last Name Child's First Name Address Gender Boy Girl Date Of Birth Parent Or Legal Guardian Name Relationship Parent Legal Guardian Cell Phone Home Phone Work Phone Email If Parent Or Guardian Is Not Available In Emergency, Notify Contact Number Relationship To Child Does The Student Have Any Of The Following Allergies? Penicillin Other drugs Insect stings Ivy poisoning Hay Fever Other None Other: Does The Student Have Any Medical Or Health Problems, And Has The Student Had Any Chronic Or Recurring Illness Or Illnesses Which Would Have An Effect On His/Her Participation In Activities? Yes No If Yes, Please Describe Problem Or Illness Please State The Name, Address, And Phone Number Of This Child's Family Physician And Any Other Physician And Dentist Who Should Be Consulted In The Event Of Emergency Or Medical Problem.
