Parental Release Form

Must be received within two weeks of applying
(This is for those who have already applied for camp.)

Thank you for your application. Please print this page and have a parent or legal guardian complete the section below. This form must be returned to the Youth Outreach Ministry Reservation Office within two weeks of applying or your tentative reservation will be released. If attending Music Academy, your audition tape/CD should also be enclosed with this form.
 
Confirmation Number  _______________________________
 
Camper Name  _______________________________
 
Camp  _______________________________
 
Address  _______________________________
 
Home Phone  _______________________________
 
School  _______________________________
 
Church  _______________________________

Emergency Information


Father’s Name ______________________________  Work Phone (_____)________________

Mother’s Name ______________________________  Work Phone (_____)________________

If a parent can’t be located, who should be contacted in case of an emergency?

Name ______________________________

Relationship _________________________  Phone (_____)______________

If you have medical insurance, attach a copy of the insurance card (front and back) and prescription card for hospital use. This prevents any delay of treatment in case of emergency.

Does this camper have an emotional or behavioral problem? ___Yes ___No
If yes, please explain on a separate sheet and also advise if he/she is under a doctor’s care for the problem.
Does this camper have a history of violent behavior toward any other children? ___Yes ___No

Is this camper on any prescription medication? ___Yes ___No
If yes, please list types and reasons for medication on a separate sheet.

A signed form for each camper must be received by Youth Outreach Ministry before camper may participate.

    I indemnify and save Youth Outreach Ministry,Inc.;Pensacola Christian College,Inc.;and its affiliates,employees,and agents harmless from any liability or medical payments resulting from my child’s participating in this camp or other activities during his/her stay at summer camp. I further understand thatYouth Outreach Ministry does not provide medical insurance coverage for my child and that any medical expenses incurred will be paid by either my own medical insurance or me. I hereby grant permission for my child to attend the camp, to participate in all the camp activities, and to be treated by a licensed medical professional in the event of any injury, accident, illness, or other situation that may require medical attention.

    I give permission for my child's picture to be used in future publications, including publication on PCC and its affiliates’ Web pages. I understand the enclosed $50 deposit is nonrefundable (if 60 days or less until camp) and nontransferable.

    Campers who use tobacco, alcohol, or any form of illegal drugs will be dismissed. Any noncooperative or noncompliant campers will be subject to dismissal.

____________________________________________ _____________________
Signature—Parent or legal guardian only Date

Send this signed form by mail to Youth Outreach Ministry, P.O. Box 18500, Pensacola, FL 32523 or by fax to 850-479-6576.