VPC Youth Overnight Trip Medical Release

Minor Name(Required)

First Last

Minor Email (if applicable)

Minor Phone Number (if applicable)

Minor Date of Birth(Required)

Minor Gender(Required)

Male

Female

Year of High School Graduation(Required)

What school do you attend?(Required)

What size t-shirt do you wear?(Required)

Minor Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian Name(Required)

First Last

Parent Guardian Phone(Required)

Parent Guardian Email(Required)

Second Parent/Guardian Name

First Last

Second Parent/Guardian Phone

Second Parent/Guardian Email

Insurance Company(Required)

Please write n/a if uninsured.

Insurance Policy Number(Required)

Please write n/a if unisured.

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Emergency Contact Relationship to Student(Required)

Medical Alerts: OTC and RX, dosage schedule

Medical Alerts: Allergies(Required)

Please list any other concerns that the trip leaders should be aware of. For instance, is this your child’s first sleep away camp, does your child tend to get carsick, sleepwalk, wet the bed, or have any other concerns? Has your child started their period and if not, have you had the necessary conversations, etc.? Does your child have any autism or sensory issues that the trip leader should be aware of?

By my signature, the parent and/or the guardian of the above minor, I grant my permission for him/her to participate fully in activities or trips sponsored by Vienna Presbyterian Church.

Signature of Parent or Legal Guardian(Required)

Today's Date(Required)

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OUR LOCATION

124 Park St, NE
Vienna, VA 22180
703.938.9050

VPC Youth Overnight Trip Medical Release

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