Camp Revive Release Form (2025)

Parental and Youth consent form is required for everyone attending camp 18 years old and under. A parent/guardian must fill out this form with camper. Please complete each section to confirm compliance for Camp Revive 2025, July 20th-25th.

By checking this box, I agree to fill out this form honestly and carefully.

Camper's Information

Camper's Full Name

Gender

Birthdate

Age when attending camp

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Emergency Contacts

Incase of emergency, please notify one of the following

Emergency Contact (Full Name & Relationship to Camper)

Cell Number

Work Number

Emergency Contact #2 (Full Name & Relationship to Camper)

Cell Number

Work Number

Special Medical Information

Please do not leave any information blank. This information is vital in case of an emergency. If any medical information changes between filling out this form and camp, please notify us.

Are you allergic to any medications? (including over the counter medications)

Please list medications you are allergic to

Do you have any other allergies or dietary restrictions?

Please list allergies/dietary restrictions

I understand it is my responsibility to fill out Camp Forest Glen's dietary restrictions form online, prior to 2 weeks before camp so they can make accommodations for me.

Yes

Will you be taking any medication(s) while you are at camp? (This includes over the counter medications as well)

Please list medications you will be taking (include medication dosage and frequency)

Do you have an emergency medication you must keep on you at all times? (rescue inhaler, epipen, insulin, etc.)

Please list medication name and what for. Include any other details you feel would be necessary for us to know pertaining to this.

Are you up to date on all immunizations?

Which ones are not up to date? This information may be vital in the case of a medical emergency.

Do you have health insurance?

Insurance Company

Group/Policy Number

Camper Medical Release

I agree to hold harmless My Hillside Church, Inc and such representatives from any or all damages, injuries, liabilities, claims, demands, or causes of action I/we, the signed, may have.

I agree

I agree to hold harmless Forest Glen Camps and Retreats and such representatives from any or all damages, injuries, liabilities, claims, demands, or causes of action I/we, the signed, may have.

I agree

I hereby give my authority and consent to medical and surgical treatment and I authorize the adult supervising sponsors to transport them at their discretion in case of an emergency.

I do

Hillside Church Image Release Form

During the year, you or your child's image/photograph or work may be used as a demonstration in workshop/classes or conferences

I/We DO give permission for our camper's images/photograph work to be used as described above. We are willing to release this into the public domain and understand that no monetary compensation will be given for the use of the materials.