Orthodox Youth Retreat
Name of Youth/Young Adult Participant:________________________________
Does your youth suffer from or has he/she been treated for any of the following:
counseling or therapy?
Hospitalized for a
Stomach or Intestinal Problems
Surgery other than
tonsillectomy, hernia repair, appendectomy or wisdom teeth removal?
High Blood Pressure
Joint or Back Problems
Under the care of a doctor or other practitioner for any
reason other than healthy child visits?
Epilepsy or other neurological problem
Known Medical Allergies: Allergic Reactions to food/s, animals, insects, medications and/or to the environment. Please clearly indicate on lines below:
Is your child up-to-date on all required immunizations?
List Additional Medical Concerns
On the Participant’s Permission Slip/Insurance Form, “Notes”
Other Important Information:
I hereby state that, to the best of my knowledge, all information indicated above is correct.
Name of Parent/Guardian (Please Print):___________________________________________
Signature of Parent/Guardian: ___________________________________________________