MINOR PERMISSION SLIP & EMERGENCY TREATMENT AUTHORIZATION/MEDICAL RELEASE
Event: In the Wild Summer Camp
Date(s):July 25, 2012 to July 27, 2012
Time(s):8:30am to 3:00pm
Location:Sherando Lake, Glenwood & Pedlar Ranger District 96 Sherando Lake Road Lyndhurst, VA 22952
Location contact #:540-349-2188
Location email address:em@sherando.com
Location website: http://www.virginia.org/Listings/PlacesToStay/SherandoLakeCamping/
Event leader:Leslie Guttenberg leslie@livingbyfaith.com 7038957939
Meet at location:The Union on July 25, 2012 at 08:30am
Return Location:Pick up at back of Youth Center on July 27, 2012 at 03:00pm
Event cost:$75.00
We will get to the event vie:Private cars/vans
Instructions:Please be advised that there is no cell phone coverage for campers at the campground. Campers may use their phones when traveling to and from the campground. Adult supervisors have cell phone access at a central point and forest rangers are also available for emergency care. We will also have a nurse at the camp.

Participant Information
First name
Last name
Teen Partner ID
Address
Contact
Medical Insurance Information
Medical Insurance Company
Policy #
Co. Contact #
Parent(s) or Legal Guardian(s)
Guardian first name
Guardian last name
Guardian Partner ID
 
Address
Contact home
Contact cell
Contact work
 
Guardian first name
Guardian last name
Guardian Partner ID
 
Address
Contact home
Contact cell
Contact work
Health Record
My child is restricted from the following activities
My child has had the following
Heart trouble Diabetes Asthma
Allergies Epilepsy/seizures
Other
 
My child is allergic to (medicines, bee stings, foods etc.)
Names, types & regularity of medications your child requires
Special instructions/information for group leaders