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MEDICAL RELEASE FORM (All Campers and Sponsors) In the event of an accident or special health needs, it will be necessary for us to have the requested information. Please make certain that you have provided thorough and accurate medical information. It is recommended that you attach a photocopy of your family medical insurance card. Name: _________________________________________________ Birth Date: _____/_____/_____ Age: ___ Sex: (M/F) _____ First Middle Last Mo. Day Year Church: ________________________________________________ City: _____________ Dates at TPCC: _____/____/____ to _____/____/____
Person to Notify in Event of Emergency: ______________________________________________ Relationship to You: __________________
Phone Number of Contact Person: Daytime (______)_______________ Evening (______)________________ Other (_______)__________ If unable to reach above person: Notify ______________________________________________ Relationship to You: __________________
Phone Number of Contact Person: Daytime (______)_______________ Evening (______)________________ Other (_______)__________ Family Physician: _________________________________________________ Phone: (_______) ______________________________ Medical Insurance Co.: ____________________________________________ Plan or Group #: ________________________________ Insured ID or Member #: ___________________________________________ Ins. Co. Phone #: (_______)_______________________ MEDICAL INFORMATION
Diseases, Chronic or Recurring Illness: (Check all that apply, explain) ‰ Asthma: _____________________________________________ ‰ Food: _______________________________________________ ‰ Bleeding Disorder: ____________________________________ ‰ Insect Sting: __________________________________________ ‰ Joint or Back Problems: _____ _________________________ ‰ Medicine/Drug: _______________________________________ ‰ Diabetes: ____________________________________________ ‰ Plant/Pollen: __________________________________________ ‰ Epilepsy: _________ ________________________________ ‰ Other: _______________________________________________ ‰ Heart Condition: _______________________________________ Special Diet: ____________________________________________ ‰ Seizures: _____________________________________________ Recent Surgery? _________________________________________ ‰ Stomach Condition: _____________________________________ Date of last Tetanus Shot? ______ Immunizations Current? ______ ‰ Emotional: ____________________________________________ HEALTH CARE AND CAMP PERMISSION² INITIAL & SIGN THE STATEMENTS BELOW.
___ I give permission for first aid techniques and simple health care to be administered as the need arises. I understand in the event of any serious injury or illness on my part the camp officials reserve the right to seek professional medical attention including but not limited to consultation with medical director, EMS transportation, and hospitalization. ___ I give permission for myselIRUP\FKLOGZDUGLQFRQVXOWDWLRQZLWKWKH&DPS+HDOWK6XSHUYLVRUDQGRUWKHPHGLFDOGLUHFWRU¶VVWDQGLQJRUGHUVWRWDNHthe following medications as indicated by checking below: ___antihistamine (i.e. Benadryl, Claritin) ___additional medications as indicated/prescribed by the HLC Medical Director I hereby attest that all information listed on this Medical Form is complete and accurate to the best of my knowledge that I or my child/ward am/is in acceptable heath, physical ability, and emotionally ready to fully participate in camp or retreat activities. I grant my permission to participate in all activities associated with the enrolled event with the exceptions of those that are noted. I, _______________________________ being the legal guardian of ______________________________________(if applicable)give my permission to 7ULQLW\3LQHV&RQIHUHQFH&HQWHU¶VPDQDJHPHQWPHGLFDOVWDIIDQGRUWKHJURXSGLUHFWRUWRSURYLGHPHGLFDOWUHDWPHQWWKDWPD\be deemed necessary to insure the well-being of myself/the named camper. I do hereby release and forever discharge all from any and all claims, demands, actions or cause of action arising out of damage or injury while participating in Trinity Pines sponsored activities. X ___________________________________________________ ____/____/____ (_______) ____________________________
Signature Date Phone Number
MEDICATION ADMINISTRATION AUTHORIZATION (Accompanies Medications) Name: _____________________________________________________ Birth date: _____/_____/_____ Age: ___ Sex: ___ Male ___ Female Church Name: _________________________________________ Church City & State: ___________________________________________ †As the parent or legal guardian of the above-named child, I give my permission to the Trinity Pines Medical Staff to administer as prescribed by law the listed below medication to my child. X_______________________________________________ _________ (______) ____________________ (______) ___________________
Parents/Guardian Signature Date Daytime Phone # Evening Phone #
OR
†As an Adult Camper/ Sponsor/Staff, I give my permission to the Trinity Pines Medical Staff to administer as prescribed by law the listed below
medication to me during my stay at Trinity Pines Conference Center.

X_________________________________________ _________
Adult Camper / Sponsor/Staff Date

For Prescription Medications only.PLEASE follow these guidelines: In accordance with Texas Department of Health regulations: ALL
Medication that is brought to camp must be: (1) Placed in a secure location not accessible to campers, (2) Prescribed for the camper (not a
sibling or parent), (3) In the original container with all labels intact, and (4) Correct current dosage.

Dosage of non-prescription medication may not exceed product recommendation withoXWGRFWRU¶VZULWWHQRUGHUV73&& staff request that you do not
send over-the-counter medications (i.e. Tylenol, Ibuprofen, Benadryl, etc). These types of medications are provided by TPCC).
Name of Medication: ____________________________________________________________________________________________________
Purpose for medication use (e.g. allergies, asthma, antibiotic) _____________________________________________________________________ Form of medication: ___ Tablet ___ Pill ___ Capsule ___Liquid ___ Inhalation ___ Other (specify) ___________________________________ Dosage (amount to be given): _________________________________ How often or at what time: ______________________________________ Remarks or special instructions: ____________________________________________________________________________________________ Name of Medication: ____________________________________________________________________________________________________
Purpose for medication use (e.g. allergies, asthma, antibiotic) _____________________________________________________________________ Form of medication: ___ Tablet ___ Pill ___ Capsule ___Liquid ___ Inhalation ___ Other (specify) ___________________________________ Dosage (amount to be given): _________________________________ How often or at what time: ______________________________________ Remarks or special instructions: ____________________________________________________________________________________________ Name of Medication: ____________________________________________________________________________________________________
Purpose for medication use (e.g. allergies, asthma, antibiotic) _____________________________________________________________________ Form of medication: ___ Tablet ___ Pill ___ Capsule ___Liquid ___ Inhalation ___ Other (specify) ___________________________________ Dosage (amount to be given): _________________________________ How often or at what time: ______________________________________ Remarks or special instructions: ____________________________________________________________________________________________ If necessary, make additional copies of this blank Medication Form in order to provide requested information for each medication. All Medication Release/Administration Forms and medication(s) to be administered should be given to the church Contact Person prior to arriving at TPCC. When
the church group arrives at camp, the Contact Person will be responsible for bringing all medications and forms to the TPCC Office. The Forms will be
reviewed by our Medical Staff to clear up any possible questions about medications or their administration. To make it easier for the church Contact
Person, the parent/or student should put their medications and signed Medication Administration Authorization forms in a zip-lock type
plastic EDJZLWKWKHVWXGHQW¶VQDPHDQGFKXUFKZULWWHQZLWKDPDUNHURQWKHRXWVLGHRIWKHEDJ
Parents should emphasize to their child(ren)
the responsibility of reporting to the camp Health Center for their medications while at camp.

Source: http://www.go2clbc.org/clientimages/31036/children/medical%20release%20form.pdf

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