doulos medical release 2010 - ydionline.org

117 Sparrow Lane; Head Waters, VA 24442 540-396-4823 ydi@ydionline.org

Doulos Registration and Medical Release Form Full name of minor:______________________________________________________

Address:_______________________________________________________________

City, State & Zip Code: __________________________________________________

Minor’s Date of Birth:____________________________________________________

Name of parent(s) or guardian: ____________________________________________

Parent holding legal custody (if separated or divorced):_________________________

Phone Numbers (of parents)

Work: ___________________________________________________________

Home: ___________________________________________________________

Cell: _____________________________________________________________

Alternate Emergency Contact

Name: ___________________________________________________________

Phone: ___________________________________________________________

Relationship to minor: ______________________________________________

Health Insurance information

Provider: _________________________________________________________

Carrier Company: __________________________________________________

Name of subscriber: ________________________________________________

Group or ID#: _____________________________________________________

Allergies (food to drug): ____________________________________________________ Are any prescription medications being taken by the minor (which will be in use in the dates of Doulos involvement?: _____ Yes ______ No

If yes, please provide the name of the medication and the dose/frequency on a separate sheet of paper. All prescriptions will be held and monitored by Head Waters Lodge/Doulos Leadership.

A Program of Youth Development, Inc.

117 Sparrow Lane; Head Waters, VA 24442 540-396-4823 ydi@ydionline.org

Is the minor under ongoing medical treatment or monitoring for any medical conditions? ______ Yes ______ No

If yes, please provide pertinent details on a separate sheet (i.e. condition and name of treating physician, with telephone #).

PLEASE READ THE FOLLOWING CAREFULLY & SIGN BELOW: I, the undersigned parent or legal guardian of the minor named herein hereby, give my permission for my child(ren) to attend and participate in Doulos at Head Waters Lodge. In consideration of the above-named minor being permitted to attend and/or participate in such activity, program or event, I agree that I will not hold Youth Development, Inc. (YDI), or their staff, agents, representatives, volunteers, or others acting on behalf of YDI responsible for any accidents, injuries, damages or losses of any kind which may arise out of my child(ren)’s attendance at and/or participation in this youth camp, and/or arising out of any transportation (including transportation in private vehicles) provided in connection with such event by or at the request of YDI, its staff, agents, representatives, or volunteers. I agree to allow decisions regarding emergency medical care for my child(ren) to be made and determined by the adult staff of Youth Development, Inc. I hereby authorize YDI, or the adult staff member or volunteer designated by Youth Development, Inc., to consent on my behalf to emergency medical, surgical or dental examination or treatment in the event that such care is required for my child(ren). I understand that I will be responsible for payment of all emergency medical expenses incurred by or on behalf of my child(ren). I further hereby authorize physicians and emergency medical personnel to provide medical attention and treatment which they, in their medical judgment, deem reasonably necessary for the emergency care of my child(ren) named above in the event of illness or injury. I agree not to hold Youth Development, Inc., or individuals acting on behalf of YDI, or as volunteers in connection with the youth camp event, liable for any negligence, or any actions or omissions, relating to emergency medical care, and absolve them from all such liability. Parent’s (Guardian’s) Name: ______________________________ ___________________________________ (Please print) (Signature) Parent’s (Guardian’s) Name: ______________________________ ____________________________________ (Please print) (Signature) Date: _____________________________