Youth Health Release Form Please fill and submit this form for all Wilderness, Junior High, & Senior High campers (fourth grade and older). Please only submit one form per child. Please visit the Parent Portal for additional forms.Section One: Child's InformationChild's Legal Name(Required) First Last Child's Nickname or Prefered NameBirth Date Month Day Year Grade this Fall4th Grade (Wilderness)5th Grade (Wilderness)6th Grade (Wilderness)7th Grade (Junior High)8th Grade (Junior High)9th Grade (Junior High)10th Grade (Senior High)11th Grade (Senior High)12th Grade (Senior High)Recent Graduate (Senior High)Gender Female Male Unaccompanied Minors(Required)Will this child attend Northern Pines with one of their parents or legal guardians? Yes. This child is attending WITH a parent or legal guardian NO. This child is attending WITHOUT a parent or legal guardian Week 1 Program(Required) Wilderness Junior High Senior High CCA Wilderness (Cabin Leader) Not Attending Week 1 Week 2 Program(Required) Wilderness Junior High Senior High CCA Wilderness (Cabin Leader) Not Attending Week 2 Child's Primary Home 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 Child's Health InformationPlease share any special health considerations which our 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.Additional InformationIs there anything else you'd like to share with program staff before this child's time at Northern Pines?Section Two: Parent/Guardian infoParent or Guardian #1Name (Parent/Guardian #1) First Last Cell Phone Number (P1)Relationship to Child (P1)Is this adult also attending Northern Pines? (P1) Yes, week 1 Yes, week 2 Yes, both weeks No Address (P1)Leave blank if the same address as the child's 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 Parent or Guardian #2Name (Parent/Guardian #2) First Last Cell Phone Number (P2)Relationship to Child (P2)Is this adult also attending Northern Pines? (P2) Yes, week 1 Yes, week 2 Yes, both weeks No Address (P2)Leave blank if the same address as parent/guardian #1 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 Section Three: Emergency ContactsWho should we contact if we are unable to reach the child's parents at above phone number(s)?Name (Emergency Contact #1) First Last Cell Phone Number (EC1)Relationship to Child (EC1)Is this adult also attending Northern Pines? (EC1) Yes, week 1 Yes, week 2 Yes, both weeks No Name (Emergency Contact #2) First Last Cell Phone Number (EC2)Relationship to Child (EC2)Is this adult also attending Northern Pines? (EC2) Yes, week 1 Yes, week 2 Yes, both weeks No Section Four: Insurance InformationPlease attach a copy of your medical insurance card with this form.Medical Insurance ProviderInsurance 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 Insured Minor: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 Thank you for filling out this Form! When you hit the "Submit" button, you will be redirected back to the Parent Portal.CommentsThis field is for validation purposes and should be left unchanged.
