2026 Model UN Medical Release Form
Student Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
School
*
Please Select
Alston Middle School
Cardinal Newman School
Eastside Family YMCA
Greenville Middle Academy
Hughes Academy
Langston Charter Middle School
Mauldin Middle School
Porter-Gaud School
Sevier Middle School
St. Joseph's Catholic School
Woodmont Middle School
St. Mary's Catholic School
First Presbyterian Academy
Fisher Middle School
Gettys Middle School
Summerville Family YMCA
If your school is not listed, please contact kell.runnion@ymcagreenville.org
Parent/Guardian Name
*
First Name
Last 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.
Please Select
Tylenol/Acetaminophen
Advil/Ibuprofen
Pepto-Bismol
Benadryl
Please select any medication you give permission for YMCA staff to administer.
Tylenol/Acetaminophen
Advil/Ibuprofen
Pepto-Bismol
Benadryl
All of the above
I have consented to my child attending the YMCA Youth in Government Middle School Model United Nations Conference in Black Mountain, NC April 2-3, 2026. 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.
*
Submit
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