First English Lutheran Church medical consent form

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First English Lutheran Church MEDICAL CONSENT FORM
Parent (Guardian) First Name
Parent (Guardian) Last Name
Address: City, State ZIP
E-mail (Note: If you wish to receive confirmation that this medical consent form was processed, you must include your e-mail address in the box on the right.)
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Primary phone and/or cell phone
Physician's First and Last Name
Physician's Phone
Insurance carrier
Insurance Policy #
Student's First Name
Student's Last Name
Allergies
List current medications
Date of last tetanus shot
List health problems
FELC may use pictures of my child on its Web site and associated media and promotions.	Yes No
Parent (guardian) signature	By entering my name in the field below, I am submitting my signature.

First English Lutheran Church                                                                                                                       E-mail: felc@felc.com
Downtown Site: 326 E. North St., Appleton, WI 54911               920.733.2303                                            FAX: 920.733.7431
North Site: Ballard Road and Broadway Drive, Appleton, WI    920.882.7942                                            FAX: 920.882.7984

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