Medical and Liability Waiver

Submit a copy for each student attending a youth event. A new form must be submitted per event.

by Student Ministry on February 21, 2021

Please submit a copy for each student attending the event. A new form must be submitted per new event.

Medical and Liability Release Form

Start and End date of the above mentioned event that this medical waiver is valid for.

For proper medicinal dosages

Gender*

Please read carefully and check all boxes.

Medical Waiver*

Liability Waiver*

Address

,  

( )   -

( )   -

If Parent/Guardian are not available, please call person above

( )   -

( )   -

Administer OTC*

I authorize PHEFC staff to administer over the counter medications appropriate to my child's symptoms/age/weight

Does the camper have any allergies to food or medication? What is the reaction? Is medication used to treat the allergic reaction?:

List any diagnosed illnesses or issues:

What medications, including doses, are used to treat the above? Any side effects of his/her medications?:

Are your child's immunizations up to date?*

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