Medical Release Form

Student Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School

School*

Parent/Guardian Name

First NameLast Name

Parent/Guardian Email

example@example.com

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Student date of birth

Insurance Carrier Name

Insurance Policy #

Insurance Policy Group # if applicable

Pre-Admission Phone number if applicable

Policy Holder (name of parent providing insurance)

Parent's employer (policy holder employer)

Emergency contact name and number in case parent cannot be located

Please list any medical conditions that may limit or affect participation at this conference.

Please list any medications your child is taking.

Please list any allergies your child has that we should know about.

Does your child carry an EpiPen?

Please select any medication you give permission for YMCA staff to administer.

I have consented to my child attending the YMCA Youth in Government High School Model Legislature and Court Conference in Columbia, SC November 5-8, 2025. In the event my child needs medical attention, I hereby grant permission to any doctor or healthcare facility to take any actions deemed necessary to protect the health and well-being of my child. This permission includes but is not limited to surgery and blood transfusions. I further agree that I will be responsible for payment for the services rendered, and I hereby agree to indemnify the YMCA and any of its employees for any expenses for caring for my child. I recognize that the YMCA is not responsible for any medical decisions made by medical personnel ,and I agree to hold the YMCA harmless for any actions taken by medical personnel. Please sign and date below.

YMCA Youth in Government Medical Release Form