Youth Camp 2025 Medical Release Form

July 24th- 28th | Evans Christian Outfitters Thurman, Ohio | This form is to ensure that medical personnel have details of any medical problem which may interfere with treatment in the case of emergency.

Parent/Guardian Information

This section will gather some information about you as the parent or guardian.

Parent/Guardian Name

Parent/Guardian Email

This address will receive a confirmation email

Parent/Guardian Phone

Parent/Guardian Address

Parent/Guardian #2

Name

This address will receive a confirmation email

Phone

Address

Child Information

Pleae fill out your childs information below.

Child Name

Child Gender

Please select one option.

Male Female

Child Age

Please select one option.

8 9 10 11 12 13 14 15 16

Emergency Contact #1

Name

Cell Phone

Work/Home Phone

Emergency Contact #2

Name

Cell Phone

Work/Home Phone

Please list those people in addition to the parents/guardians who are permitted to pick up your child:

Name

Medical Release Information

Policy Number

Name of Health Insurance

Primary Care Provider (PCP)

PCP Phone

PCP Address

Preferred Hospital

Please select one option.

Adena Holzer Kings Daughter O'bleness

Current Treatment

Please list any medical problems, including any requiring maintenance medications (ie. Diabetic, Asthma, Seizures).

Is your child presently being treated for an injury, sickness or taking any form of medication for any reason?

Please select one option.

Yes No

If yes, explain:

Allergies

Is your child allergic to any type of food or medication?

Please select all that apply.

Yes No

If yes, explain:

Special Diet

Does your child require a special diet?

Please select all that apply.

Yes No

If yes, explain:

Description

July 24th- 28th | Evans Christian Outfitters Thurman, Ohio

This form is to ensure that medical personnel have details of any medical problem which may interfere with treatment in the case of emergency.

Youth Camp 2025 Medical Release Form

Description

Please Fix the Following