HTC Youth Master Medical Form

Valid for two (2) school years, this form accomplished by Parents/Guardians is used to consolidate important Medical Information of our HTC Youth Students.

Unless otherwise indicated, this form is valid for events for the current school year and the next for our annual HTC Youth events that your student/s might be part of! These include but are not limited to UNITED Fall Retreat, RISE Winter Mission, JH Winter Camp, WITNESS Spring Break Mission and HUME LAKE Summer Camp.

Please accomplish this form and hit Submit.
 
 
 
 
 
 
 
 
 
Food Restrictions
Note: Event may require additional cost for special diet requirements.
Please select all that apply.
Medical Form
Parents/Guardians: Must check 1 OR 2 to indicate desired action in the event of an accident or emergency.
Please select one option.
Option A:

In the event of an accident or other emergency, when a parent/guardian is unavailable, I hereby authorize a representative of Harbor Trinity Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
 
 
 
 
Option B:

I do not choose the above statement and desire that the following action be taken (write below):
 
 
 
 
Health History
Please select all that apply.
 
 
 
 
Please select all that apply.
 
 
 
 
 
 
 
 
 
Please select all that apply.
 
 
 
 
Waiver of Liability
I do fully and expressly release, indemnify, and hold harmless HARBOR TRINITY CHURCH (HTC), 1230 Baker Street, Costa Mesa, California, its Board, Members, staff, employees, and their assigns from any and all liability for any harm, including, but not limited to, any accident, injury, or death, incurred by my child as a result of his/her participation in any event, including, but not limited to, any athletic, recreational, social, or other activity, sponsored or attended by HTC Youth Ministry.
 
 
 

Description

Valid for two (2) school years, this form accomplished by Parents/Guardians is used to consolidate important Medical Information of our HTC Youth Students.

Unless otherwise indicated, this form is valid for events for the current school year and the next for our annual HTC Youth events that your student/s might be part of! These include but are not limited to UNITED Fall Retreat, RISE Winter Mission, JH Winter Camp, WITNESS Spring Break Mission and HUME LAKE Summer Camp.

Please accomplish this form and hit Submit.