Pulse Youth Retreat Form

Pulse Youth Retreat Form

Date: October 10-12 (Friday-Sunday) Check in: Friday, October 10th at 6pm at the church Departure to church: Sunday Oct 12th at 9am Location Address: Dickson Valley Camp 8250 Finnie Rd. Newark IL
Student Full name*

First NameLast Name
Student Birth Date*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
E-mail*
example@example.com
Phone Number*
Parent contact*

First NameLast Name
Parent contact phone number

Area CodePhone Number
Health Details

In order for us to best serve each student on the retreat, please answer the following questions. All answers will be kept strictly confidential.

Type a question*

Rows	Yes	No
Does your child have any allergies?
Does your child carry an EpiPen or inhaler?
Does your child have any medical conditions or history we should be aware of?
Does your child take any prescription or over-the-counter medications?
Does your child require assistance with taking their medication?
Has your child had any recent illness, surgery, or injury we should be aware of?
I give permission for camp staff to provide common over-the-counter medications (Tylenol, Ibuprofen, Benadryl, Pepto-Bismol, etc.) if needed.

If you answered "Yes" to any of the questions above, give details of all occurrences. Include the following: dates, frequency, type, amount etc below
Do you have any dietary requirements/allergies?
Signature

Clear
Date Signed

MonthDayYear
Date
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