POwer uP Guided Retreat

Name of Teen
Grade Level
Email
Emergency Contact
Any food allergies?
: Off Property Form
Participants Name
Date of Birth
Street Address (St., City, Zip Code)
Parent/Guardian Name
Cell Phone Number(s) of those that can be reached in case of emergency
Event/Location
Date/Time of event.
Transportation
Method of Transportation (If transportation is Provided)
Inputting your name below is the signature for this online form. Please type your name, signing and agreeing to the above statement.
Date Signed
Participant's Name (typing is a form of signature for this online form).
Date Signed
Insurance Policy Number
Insurance Carrier
Name of Insured
Insurance Policy Number
: Medical Form
Medical Matters: I hereby warrant to the best of my knowledge, all the information provided is true and correct and I assume all responsibility for the health of my child. I understand it is my responsibility to update the Medical information and Consent Form if there are any changes to my child's health (Please, initial)
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital/clinic for emergency medical or surgical treatment (Please, initial)
Family Doctor
Family Doctor's phone number
Medications: I hereby Grant Permission for my child to be given the following provided medications. All medications must be well labeled. (Note: any/all prescriptions medications must be in original pharmacy container with young person's name on the prescription label. Non-prescription/over-the-counter medications must be in original container with young person's name on the container). I release and hold harmless Prince of Peace Catholic Church, the Diocese of Orlando and any other religious, employees, volunteers, agents and representatives from any injury or harm resulting from administering medication (Please, initial)
Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency, are as follows:
: Medical Conditions Information: (Reasonable steps will be taken to keep this information confidential, but it will be shared with Diocesan personnel and others, as warranted.)
My son/daughter is allergic to the following medications: (Please list below)
My son/daughter is allergic to the following medications
My son/daughter has had an episode of the following or has been diagnosed with seizures, asthma, diabetic
My son/daughter has had allergic reactions to the following (foods, dyes, latex, etc.)
My son/daughter has had a medical surgery within the last six months and still under doctor's care?
My son/daughter has a medically prescribed diet (please explain)
My son/daughter has the following physical limitations
Immunizations current and up to date?
Date of last tetanus/diphtheria immunization?
You should also be aware of these special medical conditions of my child:
Insurance information: Do you carry medical insurance for your child at this time?
Insurance carrier
Name of insured
Insurance Policy number
In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the participant's parent/guardian. I fully understand the forgoing statements and sign and date (by typing my name and date below) this medical information & consent form knowingly, freely, and willlingly

Prince of Peace Parish

POwer uP Guided Retreat

Off Property Form

Medical Form

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