Youth Medical Form 2026-27

Youth Information

First Name *

Middle Name

Last Name *

Preferred Name

Tip: (If different from First Name)

Date of Birth *

Gender *

Pronouns

School Grade *

School Name *

School Calendar

Email Address

Tip: Please do not enter a parent email in this field

Mobile Number

Tip: Please do not ender a parent number in this field

Home Address *

Home Address Line 2

Home City *

Home State *

Home Zip Code *

Lives With *

Date of baptism

Date of confirmation

Parent/Guardian 1 Information

Parent/Guardian 1 First Name *

Parent/Guardian 1 Last Name *

Parent/Guardian 1 Relationship to Youth *

Parent/Guardian 1 Pronouns

Has any contact information for Parent/Guardian 1 changed in the past year? (Phone, email, address?) *

Parent/Guardian 1 Cell Phone *

Parent/Guardian 1 Email *

Is Parent/Guardian 1 Address different than listed for youth address above? *

Parent/Guardian 1 Address, City, State, Zip

Parent/Guardian 2 Information

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Relationship to Youth

Parent/Guardian 2 Pronouns

Has any contact information for Parent/Guardian 2 changed in the past year? (Phone, email, address?)

Parent/Guardian 2 Email

Parent/Guardian 2 Cell Phone

Is Parent/Guardian 2 Address different than listed for youth address above?

Parent/Guardian 2 Address, City, State, Zip

Medical Information

Please list any allergies to medications, food, insect stings, etc. Enter "n/a" if there are none. *

Please list any special dietary needs or restrictions. Enter "n/a" if there are none. *

Please list all medication(s) your youth is currently taking (prescribed & over-the-counter). Include strength & dosage schedule. Enter "n/a" if there are none. *

Please list any medical conditions which should be known. *

OTC Medications

Occasionally the necessity arises to administer over-the-counter medicines for minor illness and injury. We keep our First Aid kit stocked with the following OTC medications: Ibuprofen, Acetaminophen, Sudafed, Benadryl, Pepto-Bismal, cough drops, Dramamine, cough suppressant, hydrocortisone, antibiotic ointment, migraine releif, anti-diarrheal, eye drops, calamine lotion, Tums, and others as necessary.

Unless listed below, you are indicating that you give permission for these over-the-counter medicines to be administered if necessary, under adult supervision, using the recommended dosage.

Please list any over-the-counter medications we do NOT have permission to give to your student.

Primary Care Physician Name *

Primary Care Physician Phone *

Insurance Information

Is your youth covered by health insurance? *

Insurance Company Name *

Insurance Company Phone *

Insurance Company Address, City, State, Zip *

Insurance Policy Number *

Insurance Policy Holder's ID # *

Relationship to Policy Holder *

Insurance Card Photo Required

Your Medical Form will not be considered complete until we have received a picture of the insurance card, front and back. You may email the photos to youth@firstcary.com. Please send the picture now before completing the rest of the form.

Emergency Contact Information

Emergency Contact Name (if a parent/legal guardian cannot be reached) *

Emergency Contact Cell Phone *

Emergency Contact Relationship to Youth *

Waivers and Consent

Medical Waiver

The undersigned does hereby give permission for my youth (as indicated previously on this form) to attend and participate in activities sponsored by First United Methodist Church Cary. I authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist, licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for your child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

Medical Waiver Signature *

Tip: Typing your name serves as your signature to this waiver

Off Campus and Transportation Waiver

The undersigned understands that some events are off the First United Methodist Church Cary campus/premises. I give my permission for my child to such events. The undersigned does also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by First United Methodist Church Cary. The undersigned unconditionally releases both First United Methodist Church, staff, and adult leaders of all claims.

Off Campus and Transportation Waiver Signature *

Tip: Typing your name serves as your signature to this waiver

Authority Consent

By completing this information, I indicate that I have the understanding and capacity to communicate health care decisions and that I am fully informed as to the contents of this document.

Authority Consent Signature *

Tip: Typing your name serves as your signature to this waiver