Summer Bible Camp Medical Release Form
I / we, the parent(s) of __________________________________ (child's name), do hereby grant to Rev. Paul DeYoung, pastor of Children's Ministry at Twin Oaks Presbyterian Church and Caitlin Claycomb, Children's Ministry Assistant, the right and authority to make medical decisions and to obtain medical treatment fo the aforesaid child in the event that an emergency medical situation arises while my child is on the premises of Twin Oaks Presbyterian Church.  The undersigned agrees to hold harmless an dby signing below fully releases Rev. Paul DeYoung, Caitlin Claycomb and Twin Oaks Presbyterian Church Corporation, any of their affiliates and any affiliated persons chargeable with any supervisory or any other responsibilities or liability, relating to emergency medical treatment.  I / we, the parent(s), agree to be responsible for any emergency medical expenses involved in helping our/my child.

Please provide your medical insurance information:

Insurance Name:__________________________________

Insurance Phone:__________________________________

Insurance Policy or Group Number:____________________

Please list any allergy or medical condition:

________________________________________________

________________________________________________

________________________________________________

Parent Signature:____________________________Date:_________

See also:  Summer Bible Camp,  Summer Bible Camp Registration Form and/or Children's Ministry