JYF & MYF Medical Information & Permission Form

As a part of Assembly Mennonite Church’s commitment to the safety and well being of our youth we ask that this form be filled out by the youth's parent/guardian for our own confidential records to ensure that we are aware of any special needs and are able and authorized to care for them in case of an emergency.

Personal Information for Child/Youth
Name of Youth
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Date of Birth
MM slash DD slash YYYY
School
Grade
Health Care
Please list any special Health Care needs below. Be sure to include food/drug allergies, medical conditions as well as any other information that would be helpful in an emergency.
Vaccination Status
Please indicate whether or not this child/youth is vaccinated against COVID-19.
Emergency Contact Information
Names of Parent(s)/Guardian(s)
Phone
Secondary Contact Name and Phone number
Is this person authorized to guide medical care?
Check one
- Yes
- No
Do you give permission to have your child/youth be contacted via text message?
- I do give permission
- I do not give permission
Do you give permission for Assembly to share your child's contact information with Mennonite Education Agency in their census?
- I do give permission
- I do not give permission
Consent of Parent/Guardian
By typing my name below, I give permission for my child/youth to participate in the activities of Assembly Mennonite Church from August 1st, 2022 to July 31st, 2023, including the winter live in, Winter Youth Retreat and regular drop ins. During that time, I authorize the adults in charge of Assembly Mennonite Church events and programs for youth to transport my child/youth, and to give consent for emergency medical treatment for my child in the event that neither I nor any other parent/guardian can be contacted.
Do you wish your child to be included on the Youth Contact List?
- Yes
- No

JYF & MYF Medical Information & Permission Form

JYF & MYF Medical Information & Permission Form

Personal Information for Child/Youth

Emergency Contact Information