Medical Form

A Medical Release Form for Minor Children is required for each child attending one of the summer camps at Hope Presbyterian Church. This online form can be submitted for one or more of the camps for each child.

ONLINE MEDICAL RELEASE FORM FOR MINOR CHILDREN

Medical Form

Needed for a minor to participate in a special activity

Child's Name*
First Last
Choose Programs*
Indicate which camp(s) this child plans to attend. This one form can be submitted for any or all of the camps.
- BraveHeart - June 24-27 -
- Vacation Bible School - July 8-11
- Soccer Camp - July 15-18
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Sex*
- Male
- Female
Address*
Street Address City ZIP / Postal Code
In case of emergency contact*
Phone 1*
Phone 2
Phone 3
Doctor's Name*
First Last
Doctor's Phone*
Date of last tetanus booster shot*
Date of last physical*
Allergic to (reply NONE if no allergies)*
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*
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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