High Plains Retreat Center - Medical Form - Kid City Summer Camp 2025

Medical Form

Your name *

Email address *

Medical Information

Date of Birth: *

Participant Information

Please fill out participant information below.

First Name: *

Age: *

Last Name: *

Phone Number: *

Gender: *

Parent/Guardian Information

Parent/Guardians(s): *

Parent/Guardian Phone 1: *

Parent/Guardian Phone 2: *

Emergency Contact One

Name: *

Phone: *

Emergency Contact Two

Name: *

Phone: *

Address: *

Medical Limitations/Allergies (including allergies to medicines): *

Current medications with dosage and time to be taken: *

ALL MEDICATIONS MUST BE IN ORIGINAL CONTAINERS

Required vaccinations are up to date: *

Physician: *

Physician Phone: *

Insurance Information

Insurance Provider: *

Policy Number *

Insurance Company Phone Number *

Signature

Authorization for Medical Treatment *

I authorize medical treatment as needed for this camper/child. It is understood that this authorization is given in advance of any specific diagnosis or treatment. I hereby waive all claims against and hold harmless the High Plains Retreat Center and its staff/leaders from any liability for any injuries received by this camper while at HPRC and/or participating in HPRC activities or programs. The camper listed has permission to participate in all activities including transportation and water activities, unless otherwise expressed in writing to the group leader and the HPRC staff. I understand that campers who do not cooperate with leaders or abide by camp rules may be asked to leave. Parents will be responsible for transportation and transportation costs if the camper is sent home.

Parent/Guardian Signature *

Today's Date: *

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