Medical Information/Release Form

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Note: If your son/daughter needs any medication administered during program hours, a bottle with prescription/administration information will be required.

Child(ren)s Name *

Email *

Address *

Physician/Primary Care Doctors Name/Location/Number *

Preferred Hospital; if required *

Dentist Name/Location/Number *

List of current medications *

List any known allergies (insect stings, food, drugs): *

List any dietary restrictions *

Medical conditions (asthma, diabetes, heart condition…) *

Option 1

In case of emergency, every effort will be made to contact the parents. If parents are unavailable, I agree as follows: • I authorize Youth Ambassadors Of Virginia Presents “Weekend Youth Retreat” Program, its agents and employees to obtain and consent to any medical treatment which, in the discretion of Youth Ambassadors Of Virginia Presents “Weekend Youth Retreat” Program, may appear to be reasonably necessary or which may arise during the course of my child’s participation in the program activity or event.• I agree to be responsible for all costs and expenses that may arise out of medical treatment obtained on my behalf, or on behalf of my child and as authorized by this consent.• I agree to indemnify and hold harmless Youth Ambassadors Of Virginia Presents “Weekend Youth Retreat” Program from any claims or liabilities that may be brought against Youth Ambassadors Of Virginia Presents “Weekend Youth Retreat” Program because of any actions of my child while participating in the activity or event causing injury or damage. TYPE I AGREE

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