IPHC Mississippi Conference
(Your Church Name Here)
Sandra Loar: 601-573-9391, Camp Director
Sylvia Langford: 601-624-7903 Gene Evans: 601-812-9098
Travel Consent/HealthForm
(Participating Children/Youth/Adult will not be allowed to ride the church vehiclesOR attend services/camp/activities without this form filled out)
Parent/Guardian or Adult, to save you from having to sign a form every time a trip is made we’re providing this one-time form for you to sign. If any info changes after signing this consent form, please contact your church/conference involved to update them. Each participant requires their ownform.
Name: ______
[LAST NAME] [FIRST NAME ]
Physical Address: ______
Birth Date:_____/_____/_____
I release all MS. PH Conference and/or Springs of Praise WOC personnel/volunteers or Camp personnel from any liability concerning my child on all Conference and/or Church-related activities.
Should the need arise, I give the Conference and/or Springs of PraiseLeadership permission to seek medical attention for me until next of kin can be notified.
Medical insurance policy name and #: ______
Signature: ______
Contact Cell/Home # ______you can definitely be reached at.
List below any info we need to know about you, example: Medicines, allergies, etc.
______
______
IMPORTANT------HEALTLH INFORMATION AND RELEASE------IMPORTANT
NAME: ______AGE _____ ADDRESS ______
RECORD OF ILLNESSES- PLEASE CHECK AND/OR GIVE DATE IF APPLICANT HAS HAD ANY OF THE FOLLOWING:
ABSCESSED EAR EPILEPTIC SEIZURE* RHEUMATIC FEVER
APPENDICITIS FAINTING* SCARLET FEVER
ALLERGIES* FREQUENT COLDS SINUS INFECTION
ASTHMA FREQUENT UPSET STOMACH* SKIN TROUBLE*
BRONCHITIS HEART TROUBLE SORE EAR
CHICKENPOX HERNIA* SORE THROAT
CONVULSIONS MEASLES TUBERCULOSIS
DIABETES MUMPS TYPHOID FEVER
DIPHTHERIA POLIOMYELITIS WHOOPING COUGH
OTHER: ______
RECORD OF IMMUNIZATIONS: PLEASE GIVE DATES
______DIPTHERIA ______MEASLES ______MUMPS ______POLIO ______SMALLPOX ______TETANUS
GENERAL INFORMATION: Check each item which applies to Applicant. Give additional information where needed.
Sleepwalking Bedwetting Constipation Poor Appetite
Explanation:
Recent exposure to contagious disease? Explanation: ______
Has been under medical care in past 6 months? Explanation: ______
Has physical disorder that will handicap in physical activities? Explanation: ______
Some foods disagree? Explanation: ______
EMERGENCY DATA: (Separate forms must be on file for each adult)
List two (2) persons who can be contacted in case of an emergency.
NAME: ______HOME PHONE: ______WORK PHONE:______
NAME: ______HOME PHONE: ______WORK PHONE:______
CHECK EITHER “YES” OR “NO” ON EACH OF THE FOLLOWING QUESTIONS:
Yes NoApplicant may be given medication if necessary.
Yes NoIs Applicant ALLERGIC to any medication? WHAT? ______
Yes NoI hereby authorize surgery for the above named Applicant in an emergency as determined by
Hospital/medical authorities.
RELEASE:
In consideration of my being permitted to participate in activities in or out of Mississippi, I release and discharge on behalfof myself and my legal representatives and assigns, the Mississippi IPHC and/or Springs of Praise World Outreach Center, it’s officers, employees, directors and staff, from liability for any and all loss or damage on account of injury to my person or property whether caused by negligence or otherwise, while present on the premises of MS Conference selected campgrounds or venues for activities in or out of Mississippi. I also certify that I am physically fit to participate in any activity on or connected with this trip in which I voluntarily become engaged. It is my intent that this release agreement be as broad and inclusive as permitted by the laws of the state of Mississippi or state we’re in and that it continue in full legal force and effect until I revoke it in a signed writing and provide a copy of my written cancellation to the Mississippi IPHC and/or Springs of Praise World Outreach Center.
Adult’sSignature: ______Date: ______