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)

 
   
Name:  
   
Address:  
   
City:  
   

State:

 
     
Zipcode:  
   
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
-Rubella  
     
:: 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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