Midwest YaYA Camp 2026 Medical Information and Liability Release Record

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Full Name *

Age *

Church *

Allergy(ies) *

Medication

Plants

Foods

Bee/Insect Stings

Other (List them in the follow up questions)

Not applicable

Required

List all allergies and reactions. Kindly describe in brief detail what the allergy/allergies are

What interventions are needed? *

Benadryl

Zyrtec

Epipen

Other (List them in the next section)

Not applicable

Required

If you need an intervention like an Epipen, will you have one available at camp and not expired? *

Yes

N/A

What medications are you currently taking? Kindly include the dosage

Emergency Contact Information

Full Name *

Cell Number

Relationship *

Dietary Restrictions *

Dairy-free

Gluten-free

Halal

Pescatarian

Vegan

Vegetarian

None

Other:

Are you minor? *

Yes

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