2023 PVCC Youth Camp Consent Form - Pleasant View Community Church

TRIP DESTINATION: Fairview Mountain Ministries, 404 Mason Rd, Ellenboro, NC 28040

DEPARTURE DATE: July 10, 2023

RETURN DATE: July 14, 2023

Youth's Name *

First

Last

Date of Birth *

Gender *

Male
Female

Adult's Name *

First

Last

(Please list the name of the person filling out the form)

Relation to Participating Youth *

Father
Mother
Guardian
Other (specify below)

Relation to Child *

Email *

Does your child have any allergies (food, medication, insects, etc.)? Please list & explain reaction(s):

Does your child have any medical conditions you would like us to be aware of? Please list:

Does your child hav any medications they will bring with them to camp? Please list:

Do you allow church personnel to give OTC medication to you child should the need arise (Tylenol, ibuprofen, Benadryl, etc.) *

Yes
No

Can your child swim AND do you agree to let them swim in the swimming pool and participate in water sports/activities at Fairview Mountain Ministries? *

Yes
No

Emergency Contact

Name *

First

Last

Best Phone Number *

What is the best phone number to reach you should we need to contact you?

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Would you like to add another emergency contact? *

Yes
No

Name *

First

Last

Phone *

Releases and Authroizations

All persons going on this field trip are deemed to have waived all claims against the church or representative for injury, accidents, illness, or death occurring during or by reason of field trip.
I agree to direct my child to cooperate and conform with direction and instructions of the church personnel in charge of this activity and agree to come and pick up my child should they fail to follow directions/instructions.
Medical Authorization: Should it be necessary for my child to have medical treatment while enroute to or from this event or at this event, I hereby give the church supervisors permission to use their judgment in obtaining medical service(s).
Permission is given to the healthcare provider(s) to render necessary treatment. I understand that the church has no insurance covering medical or hospital cost - such cost is my obligation.

Consent for Releases and Authorizations *

Agree
Decline

Check "Agree" if you consent to the "Releases and Authorizations" listed above

Signature *

Clear Signature

By signing, you acknowledge that you have read this form in its entirety and have answered all the questions fully and truthfully to the best of your knowledge, and are legally allowed to sign this form on behalf of the child that will be attending this event.

Date *