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* Date Format: 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 Date Format: MM slash DD slash YYYY Second Child's AgeSecond Child's Gender Male Female Third Child's Name First Last Third Child's Date of Birth Date Format: MM slash DD slash YYYY Third Child's AgeThird Child's Gender Male Female Fourth Child's Name First Last Fourth Child's Date of Birth Date Format: MM slash DD slash YYYY Fourth Child's AgeFourth 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* Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.