Dear healing challenge participants,

Emergency Contact(s): ___________________________________ Relationship: __________________ Phone number: __________________________________________ Recent, chronic, recurring illness: Any allergies (insects, food, medications, etc.): Special activity restrictions or health concerns: If under 18, please put all medications in a zip lock bag and label with name and school/group. Medications should stay in the possession of the lead chaperone, nurse, or designated person. CAMP GREENVILLE PO Box 390, Cedar Mountain, NC 28178 P 864 836 3291 F 864 836 3140 W campgreenville.org I authorize my child’s chaperone to administer over-the-counter medication for minor illnesses. I will allow the following to be dispensed (please check all that apply): I wish to be consulted before ANY over-the-counter medication is give to my child. I certify that the participant named in this document is in good physical condition and that the information provided is accurate to the best of my knowledge. Participant (if over 18) or Parent/Guardian’s Signature: *This form is to be utilized by Camp Greenville staff only in the event of an actual injury or illness. Camp Greenville staff may not review this form unless such need arises. If your child is under 18 years old, please complete the following for your child to participate in this experience. I, ______________________________, give permission for my child, ___________________, to participate in the activities at YMCA Camp Greenville in Cedar Mountain, North Carolina on CAMP GREENVILLE PO Box 390, Cedar Mountain, NC 28178 P 864 836 3291 F 864 836 3140 W campgreenville.org The following information must be completed for anyone visiting YMCA Camp Greenville. PHOTO RELEASE I give my permission for any photos or videos taken of my family or me during the outing at YMCA Camp Greenville to be used for the public relations program. I give my permission for YMCA Camp Greenville to add me to their mailing list. LIABILITY I hereby release YMCA Camp Greenville and the Greater Greenville YMCA and their employees, volunteers, and chaperones, from any financial or legal responsibility that may result from this outing. To insure prompt attention in case of serious accident or illness, I hereby authorize the persons responsible to incur expense deemed necessary and agree to pay for the same, if they are not covered by a school/agency accident and sickness policy. Should the need arise; I give permission to the YMCA Camp Greenville to take me to a doctor or hospital for medical treatment. I also authorize an agency chaperone to execute any or all documents in my behalf, including necessary releases, which might be required by a medical facility to perform emergency care. MEDICAL AUTHORIZATION AND RELEASE Should I sustain or incur an accident or illness while attending YMCA Camp Greenville, I hereby authorize an agency official to execute any and all documents in my behalf, including necessary releases, which my be required by a medical facility to perform emergency care. Telephone number of a parent or emergency contact that can be reached during the outing: Name: Cell: ____________________Work: ________________________ Second emergency contact: Name and relationship: Cell: ____________________Work: ________________________ Participant (if over 18) or Parent/Guardian’s Signature: CAMP GREENVILLE PO Box 390, Cedar Mountain, NC 28178 P 864 836 3291 F 864 836 3140 W campgreenville.org

Source: http://www.campgreenville.org/mydocuments/med_concent.pdf