MS Retreat Medical Release Form

STRIKE BACK MIDDLE SCHOOL RETREAT

June 3rd-5th 2022, Hosted by The Pack Youth Inc.
Rising 6th Graders-8th Grade Graduates; Join us for a weekend full of swimming, basketball, dodgeball, team wars, good food, bonfire, great sessions, give away, build a family, glow party, and surprises. (active nurse will be present on the campus)

Location: Camp John Hope; Fort Valley, GA
- Depart Douglasville at 4p on Friday June 3rd.
Participant's Full Name *

First Name Last Name
Participant's Birth Date *

Month Day Year
School *
Parent’s Email email *
Phone Number *

Area Code Phone Number
Last Grade Completed *
Child's Allergies or medical problems or N/A *
Any medication, limitation your students takes or needs , and how often does any medication need to be taken? Or N/A *
REQUIREMENTS

The child named above is in good health and if not you have explained in detail any medical/emotional/Physical limitations, allergies, medication, or other so that The Pack Youth Staff can best serve your student.
Type a question *

Yes
TRANSPORTATION

Adult volunteers and chaperones will transport the participants to Camp Hope, and Freddy’s for dinner Friday night, and back home Sunday.
I approve for my student *

Yes No
CONSENT

I hereby attest that I am (we are) the legal parentguardian(s) of the above-named child and hereby consent to the child's participation in the activities described above. I understand that activities of the kind described above may result in physical injury to my child but nonetheless specifically request that he or she be allowed to participate in those activities.
Type a question *

Yes No
EMERGENCIES

If the above-named child requires any emergency medical treatment or procedures during the activities, I hereby consent to and authorize the above-named activity supervisor(s) to make any decision and take any action to arrange for such procedures or treatments in the discretion of the activity supervisor(s).
Type a question *

Yes No
INSURANCE

I/We understand that The Pack Youth Inc. does not carry any insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my own insurance carrier; or (b) that I/We am personally financially responsible for any and all medical costs incurred as a result of the child's injury.
Submit a picture of the students medical insurance info if it applies

Browse Files

Cancel of
RELEASE AND LIABILITY

In consideration of being accepted by THE PACK YOUTH for participation at our YOUTH RETREAT, June 3-5 2022 we (I), being 18 years of age or older do for ourselves (myself, and for and on behalf of my child - participant) do hereby release, forever discharge, and agree to hold harmless THE PACK YOUTH and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child - participant that occurred while said child is participating in the above described trip or activity. Furthermore, we (I) and on behalf of our (my) child - participant, hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. Furthermore, authorization and permission is hereby given to said organization to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agrees to hold harmless and indemnify said organization, its Directors, employees and agents for any liability sustained by such organization as a result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

Authorization for Treatment:

We (I) are the parent(s) / legal guardian(s) of this participant, and hereby grant our (my) permission for him/her to participate fully in said trip and hereby give our (my) permission to said participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.
Parent/ Guardian Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Mom's E-mail *
Dad's E-mail
Home Phone Number

Area Code Phone Number
Mom's Cell Phone Number *

Area Code Phone Number
Dad's Cell Phone Number

Area Code Phone Number
9. Emergency Contacts

If, in the event of a medical or other emergency, I am unable to be reached by telephone at my home or work telephone numbers listed below, I authorize the activity supervisor(s) to attempt to contact me through the emergency contacts listed below.
Emergency Contact#1 Name *

First Name Last Name
Relationship *
E-mail *
Cell Phone Number *

Area Code Phone Number
Emergency Contact#2 Name

First Name Last Name
Relationship
E-mail
Cell Phone Number

Area Code Phone Number
I, the parent/guardian, hereby attest that I have carefully read this Permission to Participate, understand its contents, and agree to its terms and conditions. *

I agree
Date *

Month Day Year
Parent Signature *

Clear
Payment *

pay cash app ($thepackyouth) pay paypal other
Deposit is $50
prev next ( X )
Pay Deposit $ 50.00
this $50 reserves your students spot

Total $ 0.00
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

STRIKE BACK MIDDLE SCHOOL RETREAT

9. Emergency Contacts