Child Medical Information and Permission Form

Medical Information & Permission Form

As a part of Assembly Mennonite Church’s commitment to the safety and well being of our children we ask that this form be filled out by the child’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

  • Date Format: MM slash DD slash YYYY
  • 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.
  • Emergency Contact Information

  • Check one