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KidStruction Zone Retreat

Name *
Address *
Home Phone
Home Phone
Cell/Emergency Phone
Cell/Emergency Phone
Parent Names
Parent Names
Yes or No. Ear infections? Heart Trouble? Asthma? Please elaborate.
Yes or No. Bees, drugs, foods, other. Please elaborate.
Children's Tylenol, Children's Ibuprofen, Benadryl, Cough Syrup, Pepto-Bismol, Immodium, Neosporin, Bactine Spray, insect Repellant, Suncreeen, Solarcaine, Aloe Vera
Insurance Carrier: Insurance Number: Insurance Address & Phone: Insured's Name
The undersigned parent(s) or legal guardian(s) of the above named participant, hereby authorize his or her attendance at, participation in, and travel to and from all activities of this camp. I hereby give permission to the camp director or his representative to administer first aid, over the counter, and doctor-authorized medications. In the event I cannot be reached in a medical emergency, I give permissions to the physician selected by the camp to hospitalize, secure proper treatment for, administer medications, and to order necessary injections, anesthesia, or surgery for the above named participant. Furthermore, we (I) (and on behalf of our (my) child participant, if under the age of 21 years) hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) release Hope Congregational Church and their directors, officers, and agents from all liability for personal injury, sickness, or death, as well as property damage which may be incurred while participant is at the camp or traveling to or from the camp.
Earlier Event: April 19
Community Easter Egg Hunt
Later Event: June 8
Vacation Bible School