YC19: Camp Volunteer Youth Medical form

The following information is required to ensure that your youth's individual needs are met while they are volunteering as staff at camp. The information is confidential and will be made available only to those adults who are directly responsible for your child's care.

1. VOLUNTEER STAFF INFORMATION:

*First Name
*Last Name
*Address 1
*City
*State
*Zip
*Phone
*Email
*Birth Date:
*Gender:
Male
Female
*Grade:
*Father's Name:
*Phone:

please include area code

*Mother's Name:
*Phone:

please include area code

If divorced, who has physical custody?

2. IN CASE OF AN EMERGENCY, PLEASE CONTACT (If parents cannot be reached) :

*Name:
*Relationship:
*Phone:

please include area code

3. INSURANCE INFORMATION:

*Family Physician:
*Phone:

please include area code

*Insurance Carrier/Plan Name:
*Policy ID#
Insurance Carrier's Address, City, State:

4. MEDICAL HISTORY:

*Date of last tetanus shot:
*Date of last physical exam:
Please list any allergies:
*Taking any medications:
Yes
No
If YES, please list:
*Are you under the care of a physician?:
Yes
No
If YES, please explain:
*Vegetarian:
Yes
No
Special Dietary needs:
RELEASE STATEMENT:

We, the undersigned or legal guardian(s) of the above mentioned minor, do hereby authorize the adult leaders acting on behalf of the California-Nevada Annual Conference The United Methodist Church, as agent, and working with other nonprofit agencies to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s), especially in case of emergency, to give specific consent to any such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his or her judgment may deem advisable. I agree to pay for any medical, dental, surgical, or hospital diagnosis, treatment, or care rendered to or for said minor.

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