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Teen Yearly Health form

- Youth Ministry
  - Luke 18 Registration page
  - Teen Yearly Health form

St. Simon Youth Ministry

Health Form – November 1, 2020 through October 31, 2021
The maximum number of form submissions has been reached. This form is currently not available.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Sex REQUIRED Please fill out this field.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Year of HS Graduation REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Allergies: Please enter valid data.
- Does your child be take prescription medication on a regular basis? REQUIRED Please fill out this field.
- Can your child be responsible for taking his/her own medication? : REQUIRED Please fill out this field.
- If No, Please Contact Please enter valid data.
- Physician Name Please enter valid data.
- Physician Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Special Needs
- Agreements
  
  As the parent or guardian of my child in approving this form, I hereby state that the information included in this form is correct and give permission for my child to participate in the activity described on the reverse side of this form.
  
  I understand that my child will be under the supervision of the St. Simon Youth Ministry volunteers.
  
  I hereby give permission for my child to be transported to and from the activity in a vehicle owned by a parish or agency of the Archdiocese of St. Louis or in a private vehicle driven by an adult at least 21 years old.
  
  I recognize that there are risks inherent in participation in any activity and agree to hold the Archdiocese of St. Louis, its affiliates and its and their employees, volunteers and agents, harmless from any injury to my child or damage to or loss of personal property of my child not caused by the negligence or misconduct of the Archdiocese of St. Louis, its affiliates and its and their employees, volunteers and agents.
  
  In the case of a medical emergency, I understand that every effort will be made to contact me, but in the event that I cannot be reached, I hereby give permission for my child to be evaluated, diagnosed and treated in accordance with standard medical practice by licensed medical personnel.
  
  I hereby give permission to the Archdiocese of St. Louis/St. Simon to use any photographs or video footage taken of me in print, on their website, or Social Media sites for promotional purposes.
  
  Parent/Guardian agreement Please select this field.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- I understand that for all Youth Ministry activities there is a zero tolerance policy for the use of any mood altering chemicals (including alcohol and illegal drugs), foul language, threats or any type of abuse and inappropriate physical contact. I agree to follow this policy.
  
  Parent/Guardian agreement Please select this field.
- Participant Agreement Please select this field.
Submit

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