See A Man Be A Man (SAMBAM)
  Mentoring program of Board of Men's Ministries;
Church of Christ of the Apostolic Faith;
Jesse L. Gamble, Mentoring Program Chairman;
Ernest Walker, Director/Chairman;
District Elder Eugene Lundy, M.D., M.B.A., D.D., Pastor
:: Student Health History ::
*Click Here for the mailable, printer-friendly version  
(Requires Adobe Acrobat Reader)



Phone Number:  
Health/accident insurance company:  
Policy Number:  
Have or subject to (check if yes):
-Asthma     -Fainting spells -Convulsions
-Diabetes   -Heart trouble -Bleeding disorders


    -Allergy to any medication, food, plant, animal, or insect toxin. -Any condition that may require special care, medication, or diet.
Explain Condition(s):  
Check here if none of the above applies:)  
Have difficulty with (check if yes):
- Eyes, ears, nose, throat   -Digestion -Bed-wetting
-Lungs -Sleepwalking

Any condition now requiring regular medication? (If yes, please explain.)

Name of medication:  
Are there any restrictions of activity for medical reasons? (If yes, please explain.)  
:: Immunizations ::
    *Fill-in the date of last inoculation
-Tetanus toxoid   -Polio
-Diphtheria   -Measles
-Pertussis   -Mumps
:: Parent Authorization ::
This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by me. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the adult leader in charge to hospitalize, secure proper anesthesia, or to order injection for my son.
Parent Name:  
Date of Authorization:  
Home telephone number:  
Business telephone number:   Ext:
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