Shenandoah District Western Youth Camp for Teens and Kids Medical Release Form June 27-July 1, 2011 Student Information: Name: _______________________________ Birthday: _________________ Grade: _______ Address: _______________________________City: _________________ Zip: ___________ Home Phone: ________________ Cell Phone:________________ E-mail: _________________ Parent/Guardian Name(s): (This information is not required for persons over 21 years of age.) Father: _____________________________Mother: ________________________________ Phone (cell): ______________ (home): _____________ (Cell): _________________ Email: __________________________________________ Medical Information for Student/Sponsor: Doctor’s Name: _______________________ Doctor’s Phone Number: ____________________ Are you restricted from sports or swimming for any reason? (please circle ) Yes No If yes, explain: __________________________________________________________________________ Date of last Tetanus Toxoid Immunization: Month __________ Year ___________ Have you ever had a severe reaction to a bee/hornet sting or insect bite? (please circle) Yes No If yes, explain: __________________________________________________________________________ Medication: List all medicines that you are currently taking (include medicines such as prescribed drugs, over-the counter drugs, vitamins, and inhalers): Frequency Taken: Name of Drug: Strength: Frequency Taken: List any allergies: Food: _______________________________________________________________________ Drugs:_______________________________________________________________________ Insurance Information: Insurance Company ________________________Policy Number _____________ Group Number ______________________________ If parent cannot be reached, please notify: _________________(relationship)______________ Phone: ___________________________or ___________________________________ Parent, I give my authority and consent to the Shenandoah Wesleyan District’s sponsors/leadership to seek a doctor or qualified person to provide emergency medical treatment to the above named student in the event he/she is ill or injured while participating at Camp. I, undersigned parent/guardian of the above mentioned child who is a minor, do realize, acquit, discharge and covenant to hold harmless its sponsors and representatives from any and all actions, cases of actions, damages, and/or liabilities arising from the medical treatment of any sickness or injuries from an accident incurred by my said child during Camp. Signature of Parent/Guardian ______________________________Date __________________ Registration Form (Please Print) Name of Camper:_________________________ Address:_______________________________ City, State, Zip:__________________________ Home Church or Church Represented:____________________________ Age of Camper:__________________________ Entering Grade # in School:_________________ Phone #:_______________________________ Male
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Providing Qualitily Christian Education, in affiliation with:
Shenandoah District Western
Youth Camp

1418 West Main Street
Milton, WV  25541