VICTORY JAM CAMP MEDICAL RELEASE AND EMERGENCY PROCEDURES

ONCE THIS FORM IS COMPLETED, YOU WILL BE REDIRECTED TO GOOD HOPE CHURCH’S WEBSITE TO COMPLETE A PAYMENT FORM. AFTER THAT, YOU’RE REGISTERED!

Medical Information for Camp

Church Name

Youth Leaders Name

Youth Leaders Phone Number

Child's First Name

Child's Last Name

Child's Date of Birth

MM

DD

YYYY

Current Weight

Known Medical Conditions (For Example, Asthma, Migraines, ADHD)

Known Allergies (Drug, Food, or Environmental)

Will your child be taking any medications while at camp? If Yes please list medication

Who will be in Charge of Medication?

If they will be taking no medication please select "Child"

Child

Counselor

Camp Nurse

Medical Insurance Carrier

Insurance Policy Number

Consent

In the event my child becomes ill or injured, I authorize the camp nurse to render aid and/or administer over the counter medication, i.e., acetaminophen, ibuprofen, antibiotic ointment. In the event of an EMERGENCY, the counselor or camp nurse will call the parent/guardian at the contact number listed below. If no one can be reached, I hereby give my permission to the physician selected by the counselor or camp nurse to secure proper treatment for my child. To the fullest extent permitted by law, I release Victory Jam Camp its trustees, officers, directors, employees, agents and representatives from injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless Victory Jam Camp its trustees, officers, directors, employees, agents and representatives from any claims arising out of my minor child’s participation in the activity.

First Name

Last Name

Parent/Guardian Email

Parent/Guardian Phone Number

Please contact your youth leader if you have questions.

John Radcliffe, Youth Leader, Good Hope Church | jradcliffe@goodhopepca.com