Wilderness Youth Health Release Form

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Attendee Type

Unaccompanied Minor

Parent

Name(Required)

First Last

Gender

Female

Male

Birth Date

Age

Grade this Fall

Address

Street Address Address Line 2 City State ZIP Code

Host family at conference

Program at conference

Parent/Guardian info

Name

First Last

Phone

Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Emergency Contacts

If unable to reach parents at above phone number(s), please contact:

Name

First Last

Relationship

Phone

Name

First Last

Relationship

Phone

Health Information

Indicate 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 Information

Please attach a copy of your medical insurance card with this form.

Medical Insurance Provider

Address

Street Address Address Line 2 City State ZIP Code

Policy/Group/Account #:

Member ID #

Name of Insurance Holder

First Last

Relationship to student:

Medical Release

Reasonable 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.

Signature(Required)

Today's Date

Phone

This field is for validation purposes and should be left unchanged.

The Camp

Conference Accommodations

Programs

CCA Info

2024 Conference Information

First Time?

Location Information

Camp Pricing

Discounts & Scholarships

Our Programs

Alumni

Speaker and Program Group Photo Archives

Photos

Share Your Story

Partner with Us

Men's Work Retreat

Staff & Employment

Returning Staff Application

Staff Confirmation

Wilderness Cabin Leader Confirmation

Returning CCA Application

CCA Confirmation

NP Staff Standards of Behavior

Apply Now

Personal Reference Form

Wilderness Youth Health Release Form

Wilderness Youth Health Release Form

Parent/Guardian info

Emergency Contacts

Insurance Information

Medical Release