MEDICARE/INSURANCE INFORMATION
Medicare #: Insurance company: Policy #: Subscriber’s name
Prov.:
In case of emergency contact: NAME: PHONE:
area code: (
)
has my permission to go to New Brunswick Bible Institute, Victoria Corner, NB on November 6-7, 2015. NBBI has my permission to obtain emergency medical treatment should an emergency arise during his/her stay. Parent’s Signature
Date
November 6-7, 2015
Year
quest
Month
/ Asthma / Other Respiratory Problem / Heart Trouble / Diabetes / Convulsions / Appendicitis / Bed wetting / Sleep walking Does your child have any other problems that we should know about? / Your child’s last tetanus shot date
kids
MEDICAL HISTORY
Does your child have any known allergies? Yes No What are they? Bee Stings Penicillin Other Drugs Foods Other Does your child take any daily medications? Yes No List medications, what they are for and when they are to be taken. Date of last occurrence Does your child have a history of: