Medical Information Form


This form MUST be filled in COMPLETELY for ALL Students and Adult Leaders to participate in any event or activity with MIPC Youth Ministries. 

The information entered is kept strictly confidential, for MIPC Youth staff only.

All Activities

This form needs to be updated each year.  We will use this information for all activities your child participates in.  

Please let us know if any information changes during the course of the year.


Student's Name *
Student's Name
Address *
Cell Phone
Cell Phone
Birth Date *
Birth Date
Medical Information
Check all that apply
Allergies and Restrictions
Check all that apply
Must be current within 10 years
Emergency Contact Info
Parent/Guardian 1 *
Parent/Guardian 1
Cell Phone *
Cell Phone
Parent/Guardian 2 *
Parent/Guardian 2
Cell Phone *
Cell Phone
Other Contact *
Other Contact
Cell Phone *
Cell Phone
Medical Decisions - Other Contact
My other contact can make medical decisions when I can not be reached.
Insurance Info