Crossways
Camping Ministries: Youth Health History/Consent
Form
(mandatory form for your youth retreats)
PARTICIPANT INFORMATION (please
print)
Name:________________________________________
Sex: M F Birthdate:___/___/___
Home
address:____________________________________________________________
City:_____________________________
State:______________________ Zip:_________
Home phone:(_____)____________
Parents' Names:______________________________
If parents are not available in
the event of an emergency, notify:
Name:______________________________
Relationship:____________________________
Phone:(_____)____________
Address:___________________________________________
Health Insurance
Company:_________________________ Policy
#:________________
Insurance Company phone # ______
-- ______ -- ________
Please list any current or
previous health conditions or allergies that
leadership should be aware of:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please list any medications the
participant is currently taking, including
dose and
schedule:__________________________________________________________
_____________________________________________________________________________
PARENTAL AUTHORIZATION - MUST BE
SIGNED BY PARENT OR GUARDIAN IF PARTICIPANT IS UNDER
18. My child has permission to take part in all
retreat activities under supervision and I agree
that the camp or its personnel will not be held
responsible for accidents or personal injury arising
therefrom. In the case of medical emergency, I
understand that every effort will be made to contact
the parents or guardians of the participant. In the
event I cannot be reached, I hereby give permission
to the medical examiner selected by the Crossways
staff and Congregational Advisors to hospitalize, to
secure proper treatment for, to order injection,
anesthesia, or surgery for my child as named on this
form. CROSSWAYS DOES NOT PROVIDE MEDICAL INSURANCE.
In the event of behavioral
problems, I agree to pick up my child immediately
upon request.
PARENT/GUARDIAN
SIGNATURE:_______________________________
DATE:________
PARTICIPANT AGREEMENT As a
participant in this event, I do hereby agree to
abide by the guidelines and policies set by
Crossways and my Advisors. I understand that I will
be held responsible for my own actions and agree to
report all injuries I experience, and pay for any
damages I incur.
PARTICIPANT
SIGNATURE:_________________________________
DATE:__________
DATE OF
EVENT:__________________________
Note to Parents...
The purpose of this health form
is to provide your retreat leaders with important
information about your child's health. In case of
accident or health concern, you (or your designate)
will be contacted by your group leader. We at
Crossways are concerned that your child have careful
supervision, and that your group has taken adequate
measures to assure a safe and meaningful experience.
With that in mind we ask that you
review and acknowledge the following safety
guidelines.
1. Please advise your child to
contact the group leaders if any accident occurs or
if any first aid treatment is needed. This should be
done immediately.
2. Please advise your child to
report any damage to camp property immediately.
(This is not to get a child in trouble, but prompt
clean up of a broken window for example, can avert
accidents.)
3. Please advise your child to
follow any and all camp rules regarding alcohol use,
smoking, weak ice, sliding conditions, etc. that may
be shared by camp retreat hosts upon arrival.
Your signature will inform your
retreat leaders that you support them in their role
to assure a safe and beneficial time at camp.
____________________________________________________________________________________________
(signature)
(date)
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