Youth Group Retreat Medical Consent Form
Participant Information
Full Name
Date of Birth
Address
Phone Number
Email
Parent/Guardian Information
Parent/Guardian Name
Phone Number
Email
Medical Information
Physician Name
Physician Phone
Insurance Company
Policy Number
Allergies
Medications
Medical Conditions
Other Important Information
Consent & Authorization
I hereby grant permission for the above-named participant to attend the Youth Group Retreat and participate in all activities. In the event of an emergency, I authorize the leaders of this event to obtain medical treatment as deemed necessary.
Parent/Guardian Signature
Date