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Medical Release Form / Permission to Treat

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Emergency Contact Information: 


Parent/Guardian:

Home Phone:

Work Phone:

Secondary Contact:

Home Phone:

Work Phone:

Insurance Information:


Insurance Co.:

Group#:

Policy#:

Cardholder:

CRelationship to Cardholder:

Insurance Co. Address:

Insurance Co. Phone:

Personal Medical Information: 


Physician s Name:

Phone:

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions. 

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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