SC25 Medical Release Form

MEDICAL RELEASE FORM
Attendee Information

This form is for EVERYONE ATTENDING CAMP, Students, Adults, Leaders, Youth Pastors
Name of Attendee*

Full Legal First NameLegal Last Name
Attendee's Gender:*

MaleFemale
Attendee Birthdate*

MonthDayYear
Summer Camp Attendee

Yes

Parent / Legal Guardian Information
THE PARENT OR GUARDIAN MUST COMPLETE THIS FORM FOR

EACH MINOR ATTENDING CAMP.

We want the most current medical information on file for best possible outcomes if there is an emergency.

If your information changes before your camp date, please re-submit a new updated form and contact our office to let us know to delete the old form.
Parent Name*

First NameLast Name
Parent E-mail*
Parent Cell Number *
Parent Home Number

Area CodePhone Number
Parent Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian

Yes
Youth Worker

Yes
Guest Group Leader

Yes
Other Ministry Leader

Yes

Medications
Will the camper be bringing any medications or supplements to camp? *

YesNo
Medication Dispensing Requirements

1. ALL medication must be listed on a seperate medication check-in sheet in order for us to dispense. The linik to the medicaiton check-in sheet will be priovided after this form has been submitted. Or You can copy and paste this URL into a new window of your your web browser: https://www.pondo.org/wp-content/uploads/2022/04/Parent-Information-SC22.pdf

2. Prescription medication must be in the original container with the camper's name on the label and include physician's instructions.

3. All non prescription medications, supplements or vitamins must be in the original pacakging and will be dispensed according to package directions.

4. We keep a supply of the typical over-the-counter medications on hand to dispense should your child need care. (Tylenol, Ibuprofen, Tums, Pepto Bismol, Cough Syrup, and Benedryl). Please leave these at home.

5. All medication should be packed separetly and given to your group leader so that it can be checked in at registration EXCEPT for Epi-Pens and Emergency Inhalers.

6. Campers are encouraged to keep fast acting inhalers and Epi-pens in their possession at all times. Please clearly mark them with a permanent marker including the camper's name and group on the container as campers often misplace such items.

7. Medication is typically dispensed before/during all meal times and at 10:00 at night. If you child needs a different medication schudule please let us no.

Leader Info
Leader Email*
example@example.com
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Adult Medical Info

Do you have any medical conditions that you would like the health tech to know about during your stay at Camp Pondo? (i.e. are you diabetic, epileptic, pregnant, have a severe allergy to anything, etc.?)
Adult Medications

Your medication may not be left unattended in the cabin as there are no cabinets that lock. You may carry your medication at all times, lock it in your vehicle or we can store it in the infirmary. Please note, some medications are temperature sensitive and could become unstable if stored in very hot or cold areas.
Do you have any medications that we can store in the infirmary ?

Alternate Emergency Contact
List the name of another person who can be contacted in the event of an emergency or illness where the attendee cannot speak for themselves.

For an adult at camp, it could be a spouse, parent, sibling or friend.

For a child, this person cannot be the parent completing this form, but could be the other parent. It could also be a sister, brother, aunt, uncle, grandparent, guardian, spouse, or trusted family friend. Anyone that you give us permission to contact as long as they meet the following requirements.

In the event of an emergency, will only release information to the parent/guardian or the person listed here.

Any person listed:
- must be over the age of 18
- be able to assist in contacting you, if the attendee is a minor
- be able to give direction to our health team, should that become necessary
- be able to drive to camp, should that become necessary
Alternate Emergency Contact Name*

Full Legal Name
Cell Number *
Alternate Number
Email*
example@example.com
Relationship to Camper*

Gift Cards

This Summer we will be using an electronic gift card system for our Camp Store.
We are no longer using physical gift cards, but you can check out how our new e-gift card system works and purchase a gift card for your camper by clicking this link: pondo.org/gift-card/. A page with this link will also pop up after you have submitted this form.
REQUIRED CHECKBOX AND SIGNATURE*
Signature*
Should be Empty:

MEDICAL RELEASE FORM

Attendee Information

Camp Information

Parent / Legal Guardian Information

Medical / Health Information

Medications

Leader Info

Adult Medical Info

Adult Medications

Alternate Emergency Contact

Gift Cards