Lighthouse Missionary Church
Shining the light of Jesus to the world
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Health form
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Child's name
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age
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gender
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grade
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Family Phone Number
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Health history
Please complete the following. The information provided will be used at all youth related activities in conjunction with Lighthouse Missionary Church, including: youth group, quiz meets, camps, retreats, and other outings.
Allergies
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Please list any allergies your child may have: including foods, insects, medications, seasonal, etc. Include a description of the reaction and how it is managed. If your child has no known allergies, please write NKA. Thank you!
Chronic Concerns
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Does your child have any health concerns, disabilities, injuries? Such as Asthma, Anxiety, Depression, Diabetes, Headaches, Seizures, Menstrual cramps, Fainting, Frequent Colds, etc. If your child has no health concerns please write none that we know of.
Date and month of your child's last Tetanus Booster:
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