NAYC 2019 Medical and Information Form

Please fill out this form and click submit.

Please select one option.
Emergency Contact

Please select one option.
Health History and Information

Below please mark any of the conditions your child may have experienced. If there are none, please select the "To my knowledge, my child has no health conditions"
Please select all that apply.

The insurance of First Pentecostal Church is only a secondary insurance. If you have medical insurance your carrier will be billed for medical charges in the case of illness or injury while your child is on a child related activity. Please list your insurance information below, if you do not have insurance, please type the statement, "There is no personal insurance on this child" in the box below.
Guidelines and Student Acknowledgement

Please read with your student and have your student initial each line below.
I have read the guidelines above with my parent(s) and will abide by them.
Parent Acknowledgement

Please read, and then type Your name and date below.

I, the parent of the child listed on this form, hereby give permission to my child to attend the function listed at the top of this form. I realize that my insurance is primary insurance and that the insurance of First Pentecostal Church is only the secondary insurance. Furthermore I understand that any medication, including everyday over the counter medication cannot be distributed unless I give my consent and list the medication and dosing instructions listed above. Finally, I have read and understand the guidelines listed above. By typing my name below, I hereby agree to these terms and conditions and give my permission.


Please fill out this form and click submit.