Hillcrest Baptist Church York

Student name (only ONE per form):

Medications being taken:

Please list all medications (including over the counter or non-prescription drugs) taken routinely. Bring enough medication to last the entire trip. Keep it in the original packaging/bottle that identifies the prescribing physician (for prescription drug), the name of the medication, the dosage, frequency of administration and the name of the person it is prescribed to. Otherwise the medication will NOT be administered by the camp nurse.

Please select one:
This person takes NO medication on a routine basis.
This person takes medication routinely.

My child is allowed OTC medications such as Tylenol, Benadryl, Advil, etc.
Yes
No

Please list all known allergies; describe the reaction and management of the reaction.

Medication allergies:

Food allergies:

Other allergies; asthma, insect bites, environmental, etc.:

Identify any medications taken during the school year that the participant does/may not take during the summer:

Medication #1 name:

Dosage:

Specific time(s) taken each day:

Reason for medication:

Medication #2 name:

Dosage:

Specific time(s) taken each day:

Reason for medication:

AUTHORIZATION FOR CUSTODIANS CONSENT TO MEDIAL CARE FOR A MINOR:

The undersigned does hereby authorize any adult representative of Hillcrest Baptist Church to consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the above-named minor which is deemed advisable by and to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the MEDICAL PRACTICE ACT, or of any dentist licensed under the provisions of the DENTAL PRACTICE ACT. The authorization will remain effective at any time during which the above-named minor is in the care of Hillcrest Baptist Church from the dates: 03.01.25 through and including 12.31.25, unless revoked in writing by the undersigned. The undersigned does further release the above-named child to accompany and/or participate with the student minister and/or student leadership of Hillcrest Baptist Church on any trip/church activities that are designated as part of the curriculum for the Student Department programs. This includes, but is not limited to, Summer camp, Servolution projects, D-Now or any other church related events.

NAME OF INSURER:

POLICY or GROUP NUMBER:

I understand by completing this online form that I am giving my child permission to attend Summercamp from 06.09.25-06.13.25 and verify that I have read the entirety of this online form and agree with its contents.
Yes
No

Please use your legal name for this e-signature.

SUMMER CAMP 2025
PERMISSION FORM

Please fill out a form for each child, for legal purposes multiple children cannot be on one form.

Medications being taken:

Please list all known allergies; describe the reaction and management of the reaction.

AUTHORIZATION FOR CUSTODIANS CONSENT TO MEDIAL CARE FOR A MINOR:

SUMMER CAMP 2025 PERMISSION FORM

Please fill out a form for each child, for legal purposes multiple children cannot be on one form.

Medications being taken:

Please list all known allergies; describe the reaction and management of the reaction.

AUTHORIZATION FOR CUSTODIANS CONSENT TO MEDIAL CARE FOR A MINOR:

SUMMER CAMP 2025
PERMISSION FORM