EmailMeForm
YOUTH LEADERSHIP RETREAT MEDICAL CONSENT
This consent form is to be used by retreat staff only after every effort is made to contact the parent or guardian and only in the case of an emergency.
I hereby give:
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First
MI
Last
(Please type student's name in the above space.)
Permission to attend and participate in all activities at the Youth Leadership Exploration Retreat.
Student Date of Birth
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MM
/
DD
/
YYYY
Parent/Guardian Name
*
First
MI
Last
Parent Cell Phone
*
###
-
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-
####
Parent Work Phone
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###
-
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-
####
Also the student:
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is not allowed to swim
is allowed to swim
Please select one
Supervision
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Parental consent granted
Students will be supervised by staff or parents although adult supervisors will be present. (Example: When students are in the game room at the hotel they will be treated as any other visitor and will be subject to the same level of supervision by the hotel staff as any other visitor.)
Indemnify and Hold Harmless
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Parental consent granted
I do hereby, as parent/legal guardian/managing conservator, and on behalf of the student agree to indemnify and hold harmless the organizers of this activity from any claim or action for property damage, personal injury, or death arising from on or on account of such activity, regardless of whether such claim or action is founded in whole or in part upon the alleged negligence of the organizers, its agent, employees, or representatives. I am participating in these activities of my own free choice. My signature below acknowledges that I have been informed of the reasonably expected hazards associated with the activity in which my child will be participating.
Consent to Any and All Medical *
*
Parental consent granted
Checking the box above signifies the patient do hereby consent to any and all medical and surgical treatments including anesthesia and operations, which may be deemed advisable by his/her physicians and surgeons. The intention hereof being to grant authority to administer and to perform all singularly and examinations, treatments, anesthetics, operations and diagnostic procedures which may now or during the course of the patient's care be deemed advisable or necessary. We also agree that the patient when admitted is to remain in the hospital until his/her physician recommends the patient's discharge.
1. List Physical restrictions (if any) below.
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If this doesn't apply write none
2. List any allergies that may effect participation.
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If this doesn't apply write none
3. List restrictions (if any) to medication.
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If this doesn't apply write none
4. List any medication the student may be taking.
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If this doesn't apply write none