STRONGER 2023 MEDICAL/PERMISSION FORM
Name
*
First Name
Last Name
INSURANCE COMPANY
*
INSURANCE POLICY #
*
UNDER NAME OF:
*
RELATIONSHIP TO STUDENT:
*
Please List any Medications taking or allergies/physical/mental/dietary conditions that we should be aware of?
*
EMERGENCY CONTACT NAME
*
First Name
Last Name
EMERGENCY CONTACT NUMBER:
*
-
Area Code
Phone Number
OPC MILFORD Staff is allowed to give my student over the counter medications for minor ailments.
*
YES
N0
In case of medical emergency or general medical care, I give consent for medical treatment for my child named above by authorized personnel. I certify the above child has my permission to attend the Stronger Camp with the Oak Pointe Church High school School Ministry August 4-6th, 2023. I will not hold Oak Pointe Church, it’s staff or volunteers responsible for any injuries my child encounters during the weekend. I understand that my child will ride in Church, volunteer or rented vehicles and that Oak Pointe Church High School Staff will do all they can to ensure a safe and fun activity.
PARENT/GUARDIAN SIGNATURE
*
PARENT/GUARDIAN NAME
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: