2018 YOUTH LEADERSHIP RETREAT MEDICAL CONSENT
This consent form is to be used by retreat staff only after every effort is made to contact the parent or guardian and only in the case of an emergency.
  • (Please type student's name in the above space.)
    Permission to attend and participate in all activities at the Youth Leadership Exploration Retreat.
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  • Please select one
  • Students will be supervised by staff or parents although adult supervisors will be present. (Example: When students are in the game room at the hotel they will be treated as any other visitor and will be subject to the same level of supervision by the hotel staff as any other visitor.)
  • I do hereby, as parent/legal guardian/managing conservator, and on behalf of the student agree to indemnify and hold harmless the organizers of this activity from any claim or action for property damage, personal injury, or death arising from on or on account of such activity, regardless of whether such claim or action is founded in whole or in part upon the alleged negligence of the organizers, its agent, employees, or representatives. I am participating in these activities of my own free choice. My signature below acknowledges that I have been informed of the reasonably expected hazards associated with the activity in which my child will be participating.
  • Checking the box above signifies the patient do hereby consent to any and all medical and surgical treatments including anesthesia and operations, which may be deemed advisable by his/her physicians and surgeons. The intention hereof being to grant authority to administer and to perform all singularly and examinations, treatments, anesthetics, operations and diagnostic procedures which may now or during the course of the patient's care be deemed advisable or necessary. We also agree that the patient when admitted is to remain in the hospital until his/her physician recommends the patient's discharge.
  • If this doesn't apply write none
  • If this doesn't apply write none
  • If this doesn't apply write none
  • If this doesn't apply write none