Youth Retreat Medical Form Retreat Medical Form for Minors 2020 Youth Retreat - medical Parent or Guardian's Name* First Last Parent Email* Enter Email Confirm Email Address* Street Address City ZIP / Postal Code First Child's Name* First Last First Child's Date of Birth* MM slash DD slash YYYY First Child's Age* First Child's Gender* Male Female Second Child's Name First Last Second Child's Date of Birth MM slash DD slash YYYY Second Child's Age Second Child's Gender Male Female Third Child's Name First Last Third Child's Date of Birth MM slash DD slash YYYY Third Child's Age Third Child's Gender Male Female Fourth Child's Name First Last Fourth Child's Date of Birth MM slash DD slash YYYY Fourth Child's Age Fourth Child's Gender Male Female In case of emergency contact* Phone 1*Phone 2Phone 3Doctor's Name* First Last Doctor's Phone*Any medical needs? (Reply NONE if no special needs)*Medication presently being used (reply NONE if no meds)*Limitations or restrictions while at activity (reply NONE if no restrictions)*Insurance Compancy/Policy # Consent*In case of emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give Hope Presbyterian Church permission to act on my behalf in seeking emergency treatment for my child in the event the representatives of the church deem such treatment necessary. I give permission to those administering emergency medical treatment to do so, using those measures deemed necessary. I absolve Hope Presbyterian Church and their designated representatives from liability in acting on my behalf. I agree.Name of Parent/Guardian submitting this form* First Last Date of submission* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.