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 2
Phone 3
Doctor'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
Name
This field is for validation purposes and should be left unchanged.

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