Iowa Kids Camp Parental Release / Medical Information

2026 Kids Camp Parental Release / Medical Form
THIS IS 1 OF 3 FORMS TO COMPLETE
General Information
Camper Name

First NameLast Name
Parent/Guardian Name

First NameLast Name
Parental Consent
The above named participant intends to attend and take part in Iowa Kids Camp. The persons signing this document represents to Iowa Kids Camp that he/she is authorized to a) grant permission for the participant to take part in this camp, and b) sign this document.

1. I realize that Iowa Kids Camp intends to take all necessary precautions against injuries and accidents. I, the undersigned hearby release, and hold harmless Iowa Kids Camp from any and all liability and responisibility whatsoever, however caused, for all damages, claims, and demands and/or cause of action that I or assigns may have for any loss, illness, personal injury, death, or property damage arising out of, connected with, or in any manner pertaining to the above named participant attendance at Iowa Kids Camp. Activities offered by Iowa Kids Camp in which participant may participate may include but are not limited to the following: Group games, Climbing Wall, Zipline, Water Slide, and Swimming.

2. I fully understand there are potential risks and hazards associated with the Activiites and with Iowa Kids Camp that is located at Willowbrook Bible Camp in Des Moines, Iowa. I have voluntarily chosen, granted permisson to the above named participant to participate in the activities and/or to be in on, or upon the property of Willowbrook Bible Camp, and I voluntarily assume all risks and responsibilty for any resulting loss, property damage, illness, personal injury, and/or death, whether cause by negligence of the Releasees, accident or deliberate act, omission or otherwise. I further agree to make restitution for any damages incurred while the above named participant participates in the Activities of Iowa Kids Camp and upon the property of Willowbrook Bible Camp.

3. I hereby grant Iowa Kids Camp permission to use a photgraph or other image or likeness of the above named participant for use in Iowa Kids Camp approved publicity, including by not limited to brochures, websites, and social media. IF the following blank is initialed, I do NOT grant permission for the use of the participant's image and likeness. _________

4. In signing this agreement, I acknowlege and reprensent that I have read and understood this document, that I sign it voluntarily, and no oral respresentations, statements, or inducements have been made. I am the parent/guardian of the participant. I understand that I am giving up substantial rights by signing this document and voluntarily agree to be bound by it
Parental Consent: Parent/Guardian Signature
Date of Signature

MonthDayYear
Date
Camper Medical Information
Camper Date of Birth

MonthDayYear
Date
Do you have Health Insurance coverage for the camper?
Health Insurance Company
Health Insurance Policy Number
Does the camper have any allergies?
List all allergies and the type of reaction they cause
Does the camper have an epi-pen? If so, they must keep it with them at all times!
Does the camper have any special food restrictions?
Please list any special food restrictions
Does the camper take any medications they will take during the week of camp?
IMPORTANT: All medications must be in the original package (daily sorters/pill keepers are not permitted.) If the instructions are different than written on the prescription bottle please let us know at Registration - and bring a signed doctor's note of the changes. Please only send enough medication for the week of camp.
List medications and when they must be taken (example: At Breakfast, At Lunch, Before Bed, As Needed)
Has the the camper been diagnosed with asthma by a physician?
IMPORTANT: If your child has been diagnosed with asthma by a physician and has medication including tablets, nebulizers, or inhalers, they MUST bring such treatment wtih them to camp or they will not be allowed to stay at camp!

If your child has an inhaler, they must keep it with them at ALL TIMES during camp!
Does the camper have any other significant health history (heart condition, diabetes, any injury) or does the camper have any restrictions/medical conditions that the medical staff needs to be aware of?
If Yes, please explain
Over the Counter Medications Permitted

Please select Yes or No to the following medications your child may or may not be given at camp
May we give your child...
Tylenol?
Ibuprofen?
Pepto Bismol?
Tums?
Benadryl?
Visine?
Neosporin?
Hydrocortisone Cream?
Emergency Contacts
Primary Contact: In case of emergency, please contact the following person

First NameLast Name
Primary Contact relationship to student
Primary Contact Home Phone Number

Area CodePhone Number
Primary Contact Cell Phone Number

Area CodePhone Number
Primary Contact Work Number

Area CodePhone Number
Secondary Contact: In case of emergency, please contact the following person

First NameLast Name
Secondary Contact relationship to student
Secondary Contact Home Phone Number

Area CodePhone Number
Secondary Contact Cell Phone Number

Area CodePhone Number
Secondary Contact Work Number

Area CodePhone Number
Medical Information Signature
Routine Care: I grant permission for the Iowa Kids Camp Health Official to give my child first aid and treat illnesses in accordance with the camp's standard care procedures

In an Emergency: I grant permission to Iowa Kids Camp to secure emergency medical/surgical treatment if necessary for the camper named on this form while at camp. I understand the camp will make every possible effort to contact me prior to emergency treatment. In the event I am unavailable, emergency treatment will not be withheld or delayed to contact me.

Assumption of Risk: Having read the camp description, I understand there are risks inherent to camping activities (outdoor activities, sports, aquatics, transportation, etc) and I grant permission for my child to partcipate.
Parent/Guardian Name

First NameLast Name
Medical Information: Parent/Guardian Signature
Date of Signature

MonthDayYear
Date
Parent/Guardian Email Address:
example@example.com
Should be Empty:

2026 Kids Camp Parental Release / Medical Form

General Information

Parental Consent

Camper Medical Information

Over the Counter Medications Permitted

Emergency Contacts

Medical Information Signature