Grace World Outreach Church
	PARENTAL CONSENT FORM
Health History
Please Print
Name					Age		Birthdate
Address							Phone
City					State		Zip Code
School					Grade In or Just Completed
Parent(s) Business Phones
HAVE YOU EVER BEEN TREATED FOR ANY OF THE FOLLOWING? (IF YES, [x])
	[  ]  HEART DISEASE				[  ]  ASTHMA
	[  ]  SEIZURES				[  ]  ALLERGIES
	[  ]  HIGH BLOOD PRESSURE				[  ]  BRONCHITIS
	[  ]  DIABETES
PLEASE PROVIDE ANY ADDITIONAL INFORMATION ABOUT ANY ITEMS (CHECKED YES) ABOVE:
DATE OF LAST TETANUS BOOSTER							20
DO YOU WEAR: (IF YES [X])
	[  ]  CONTACTS		[  ] GLASSES		[  ]  DENTAL APPLIANCES
PLEASE IDENTIFY ANY PHYSICAL IMPAIRMENTS OR LIMITATIONS:
PLEASE LIST ANY MEDICATIONS BEING TAKEN:
IN CASE OF AN EMERGENCY, I HEREBY GIVE PERMISSION TO THE PHYSICIAN TO RENDER TREATMENT.
SHOULD THE PHYSICIAN DEEM IT NECESSARY, I AUTHORIZE HOSPITALIZATION, ANESTHESIA, SURGERY
OR INJECTION OF MEDICATION.
SIGNATURE (PARENT IF MINOR)						DATE
STATE OF FLORIDA - COUNTY OF HERNANDO
The foregoing instrument was acknowledged before me this ____ day of ________________, 20 ____.
The above person is personally known to me or has shown me a photo ID verifying who they are.
					NOTARY PUBLIC