2022 Summer Camp Medical Release

2023 Summer Camp Medical Release

First Name *

Last Name *

Age *

Grade *

Street Address *

City *

State *

Zip Code *

Mailing Address if different from above

Student Email Address *

Student Phone Number *

Student Insurance Company *

Insurance Carrier Phone Number *

Mothers First & Last Name

Mothers Cell Phone Number

Mothers Email Address

Fathers First & Last Name

Cell Phone Number

Fathers Email Address

Additional Emergency Contat Person

Addtional Emergency Contact Cell Phone Number

Physician Name *

Phone Number *

Dentist Name

Phone Number *

List allergies: *

Brief Health History: Athsma/Stomach or digestion/Epilepsy or seizures/Heart/Diebeties/Physical or Mental health concerns *

Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken.

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Date of last Tetanus shot: *

Glasses Required? *

Please list acceptable over the counter medications Adult Chaperones or medical personnel may administer, if necessary, without parent consent: Examples Tylenol, Mortin, Imodium, Peptobismal, Benadryl, etc. *

I, the student, have read the rules of conduct, and the health and and safety limitations previously stated, I agree to abide by the personal limitations previously stated as well as the code of conduct while participating in all activities.

Activities may include, but are not limited to: cookouts, boating, swimming, basketball, roller skating, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, skiing, snowboarding, sledding, hiking, biking, horseback riding, service projects, mission trips, scavenger hunts, concerts, Bible studies, miniature golf, hayrides, hide & go seek, water balloon fights, capture the flag, bowling. (Transportation to/from activities may be included as part of that activity).

Note: If you desire to limit your child’s participation in any event (including transportation), please submit your wishes in writing to the church youth pastor prior to that event.

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I, the student, have read the rules of conduct, and the health and and safety limitations previously stated, I agree to abide by the personal limitations previously stated as well as the code of conduct while participating in all activities.

Activities may include, but are not limited to: cookouts, boating, swimming, basketball, roller skating, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, skiing, snowboarding, sledding, hiking, biking, horseback riding, service projects, mission trips, scavenger hunts, concerts, Bible studies, miniature golf, hayrides, hide & go seek, water balloon fights, capture the flag, bowling. (Transportation to/from activities may be included as part of that activity).

Note: If you desire to limit your child’s participation in any event (including transportation), please submit your wishes in writing to the church youth pastor prior to that event.

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Parent Signature: By signing I/We agree the student has applicant has my permission to attend and be transported to and from all youth group activities sponsored by RMRCOG for the 2022 calendar year.

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child.I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

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