Unaccompanied Minor Health Release Form Please fill and submit this form for all minors who will be attending Northern Pines without a legal guardian (campers, CCAs, or staff ages 0–18). For children third grade and younger, please also fill out the Children's Program Information Form. The Youth Program Health form is not needed in addition to this form for minors in forth grade and older.Name(Required) First Last Gender Female Male Birth Date Month Day Year AgePlease enter a number from 0 to 18.Grade this FallPlease enter a number from 0 to 13.Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Host family at conference Program at conference Parent/Guardian infoName First Last PhoneName First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactsIf unable to reach parents at above phone number(s), please contact:Name First Last Relationship PhoneName First Last Relationship PhoneHealth InformationIndicate any special health considerations of which our program staff should be aware. These include allergies or other conditions which might need attention at the conference. List any medication to be taken while at the conference. If more space is needed, please continue on the back.Insurance InformationMedical Insurance Provider Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy/Group/Account #: Member ID # Name of Insurance Holder First Last Relationship to student: Medical ReleaseReasonable effort will be made to reach you in the event of an accident or illness involving your child who requires medical attention. If you cannot be reached, your signature on the following release will ensure prompt care.Consent(Required)As parents/guardians of the student named on this release, we authorize the staff, officers, or directors of Northern Pines of Minnesota, Inc. or any licensed physician or nurse who may be in attendance to act as our agents in arranging for and consenting to any medical care or attention which may be required or seem appropriate while he/she is at a Northern Pines conference activity. It is understood that this authorization is given in advance of any specific medical attention being required, and is given to provide Northern Pines and its representatives with the authority to act on our behalf. I agree to the privacy policy.Signature(Required)Today's Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
