PACIFIC NORTHWEST QUARTERLY MEETING - April 24 - 26, 2020

Youth Medical Release and Information Form

Use a separate form for each child.

Bring 2 copies per child if a parent will be present. Send 3 copies per child if a sponsor will be present.

Child’s name:

DOB:

Age Group/Grade: preschool[]  K-2nd[]  3rd-5th[]  6th-8th[]  9th-12th[]

Child’s physician:

Phone:

Health Insurance Provider:

ID#(s):

Medications:

 

Date of last tetanus shot:

 

Please use the back of this form for any additional information the program should know about your child, such as how s/he interacts with others, any learning differences, good friends or favorite foods.

I give my child permission to attend children’s activities and programs at the PNQM Quarterly Meeting at Lazy F Camp near Ellensburg, Washington, from Friday, April 24, 2020 through Sunday, April 26, 2020. Activities may include walking field trips outside of the Lazy F Camp. The undersigned parent or legal guardian of the above named minor hereby authorizes Karma Arslanian, or one of the other adult leaders of the child’s programs, to consent to any emergency medical or surgical treatment of said minor, which such person deems advisable at his or her discretion. This authorization will be in effect on the days listed above, during the hours of the PNQM Children’s Program, until the child is signed out by the parent, legal guardian or sponsor.

(yes/no) I also give permission for my child to participate in a hike on the afternoon of Saturday, April 25, 2020. The activity planned is to hike to the cross at the top of the hill adjacent to the camp.

Please ask questions about the field trip: Karma Arslanian, karma.arslanian@gmail.com, (970)599-3503 . If you decide your child will not participate, an alternative on site activity will be agreed upon.



Parent’s Signature

Date

IF NO PARENT WILL BE WITH THIS CHILD DURING QUARTERLY MEETING

Adult sponsor's name: Meeting:

Secondary Sponsor's name:

The undersigned parent or legal guardian of the above named minor hereby authorizes

(sponsor) to consent to any emergency medical or surgical treatment of said minor which such person deems advisable at his or her discretion. This authorization will be in effect on the days listed above, beginning with transport of minor to PNQM and ending upon return to parent(s) or legal guardian. If a person other than the above listed sponsor is to provide transportation, a secondary sponsor shall also be designated and sign below. Secondary sponsor will have the same discretion for authorizing treatment as the main sponsor.

I give my child permission to attend the PNQM Quarterly Meeting at Lazy F Camp near Ellensburg, Washington, from Friday, April 24, 2020 through Sunday, April 26, 2020, under the care of the adult sponsor(s) listed on this form.

Parent's Signature

Date

 

I agree to assume responsibility for the above named minor during the dates listed.

Sponsor's Signature

Date

 

Secondary Sponsor's Signature

Date

 

During Quarterly Meeting the parent or legal guardian of the above named minor will be at the following location:

Name:

Address:

Phone:


Name:

Address:

Phone: