2012 Youth Medical Information & Release
Parents of Youth participating in the 2011 Youth Program are asked to print & complete the Medical Information & Release forms below. The forms may be mailed to LVCM PO Box 601 Elizabethville PA 17023 attn Youth Committee or they may be submitted at campmeeting. On-line Youth registrations should, also, be completed and submitted.
Name of Youth ____________________________________
Insurance Name __________________________________
Contract or ID No. _________________________________
Any known allergies __________________________________________________
Please list medication and condition for which it is prescribed. Note medication must self-administered.
Camp representatives cannot be responsible for administering medications.
Medications needed (& conditions for ea.) ______________________________
Family Doctor (name, address, phone no.) ________________________________
Emergency contact(s) ______________________________ Phone _____________
(in the event of an emergency, all attempts will be made to contact a parent/guardian,
if unsuccessful, emergency contact will be notified)
By signing this form, you acknowledge participation in LVCMA Youth Group activities/events, held at Lykens Valley Camp or other locations, and release and discharge LVCMA from liability. You further give permission for your child to be transported in vehicles for Youth activities/events.
You hereby authorize LVCMA to use or disclose health information for purposes of treatment as allowed by law in connection with any accident or medical incident.
I have seen, read, and agree to the above.
Youth Signature _____________________________________ Date ___________
Parent/Guardian Signature _____________________________ Date __________
Parent/Guardian Signature ______________________________ Date ___________
(If you feel any additional information is needed, please use the back of this form, sign and date. Thank you.)