PACIFIC NORTHWEST QUARTERLY MEETING - April 27 - 29, 2018

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: __________________

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 27, 2018 through Sunday, April 29, 2018. 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 Linda Ellsworth, 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 28, 2018. 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: Linda Ellsworth, sandboa51@msn.com, (360) 376-2154. 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: _________________________ Meeting: ______________________

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 27, 2018 through Sunday, April 29, 2018, 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: __________________________