Camping Health, Consent And Release Form - Young Life
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1
2FOR AREA DIRECTORS
INTERNATIONAL SCHOOLS SERVICE PROJECT
Area # ______________________
CAMPING HEALTH, CONSENT AND RELEASE FORM
Area Name __________________
Trip Leader/Area Dir. __________
School Name ________________
Camp Dates _________________
This form is only good for travel to and from, and attendance at, this specific camp; it may not be used for any other
q
q
q
Camper
Leader
A-Team
camping trip. A new form must be completed for each Young Life Camp experience.
q
q
Summer Staff
Work Crew
Note to Parent/Guardian/Guest: Young Life wants the camp experience to be a safe and healthy one. However, in the event of an
accident or illness, it is important that we have the following information:
q
Summer Staff
1.
Medical history;
2.
Medical insurance information; and
3.
Pregnant Teens: Pregnant teens up to 34 weeks and teen moms 6 to 12 weeks post-delivery on camp date must have a physician’s release., and teen moms less than
6 weeks post delivery on camp date may not attend. Pregnant teens over 34 weeks to full term are not allowed to attend camp.
Please make a copy for your records. Camps are unable to fax or send copies to other camps
.
Email ____________________________________
Name ____________________________________________________________________ Birthdate __________ Sex __________ Age _______
Last
First
Middle Initial
Issuing Country of Passport ________________________________Passport Number ________________________ Date of Expiry____________
Parent or Guardian (or spouse) ________________________________________________________
Cell Phone ________________________
Home Address _____________________________________________________________________ Home Phone ________________________
Street Address
City
Country
Postal Code
Business Address ___________________________________________________________________
Phone ________________________
Second Parent or Guardian Emergency Contact _______________________________________________________________________________
Home Address _____________________________________________________________________ Home Phone ________________________
Street Address
City
Country
Postal Code
Business Address ___________________________________________________________________
Phone ________________________
Street Address
City
Country
Postal Code
If not available in an emergency, notify: Name _________________________________________________________________________________
Home Address _____________________________________________________________________ Home Phone ________________________
Street Address
City
Country
Postal Code
ACCIDENT COVERAGE
I understand that my personal insurance will be primary coverage for camper accidents and that Young Life’s insurance is secondary up to a maximum of
$20,000 ($4,000 for dental claims). Exception: if the total claim is less than $250, Young Life will pay the full amount. On claims above $250, Young Life will
coordinate payments for deductibles and co-pays. Young Life’s policy does not cover camper illnesses. If you have questions, please contact Young Life
Benefits and Insurance at (719) 381-1950.
q My insurance company _____________________________________________________________________________________
3
PROVIDE
Policy Number _______________________________________________________________________________________
Insurance
Information
3
Insurance company address _________________________________________________________________________________
q Not currently insured – Young Life reserves the right to subrogation if it is later determined that personal medical insurance was in
place.
A parent can complete the following health care recommendations.
In my opinion, the applicant’s condition q does q does not preclude his/her participation in an active camp program.
The applicant is authorized to carry an inhaler, epi pen and other emergency medications with them at all times? Yes_____ No _____
Height ____________ Weight ______________ Blood Pressure if known ______________________
The applicant is under the care of a physician for the following condition(s) __________________________________________________________
_______________________________________________________________________________________________________________________________________
Any treatment or medication to be continued at camp (specify dosages)_____________________________________________________________
_______________________________________________________________________________________________________________________________________
Chronic or recurring illness or medical condition (including behavioral conditions); operations or serious injuries (dates)________________________
_______________________________________________________________________________________________________________________________________
Explanation of any reported loss of consciousness, convulsion or concussion _________________________________________________________
_______________________________________________________________________________________________________________________________________
Any allergies (food, drugs, plants, insects) ____________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Any medically-prescribed meal plan or dietary restrictions ________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Any camp activities from which child should be excluded?
_______________________________________________________________________________________________________________________________________
Name and phone of family physician ________________________________________________________________________________________
Name and phone of dentist/orthodontist______________________________________________________________________________________
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