Spring Break Service Trip 2024

March 10-13

Oklahoma City

Limited to 8 Youth and 1 Adult (prefer female)

2024 Spring Break Trip Medical Release and Permission Form

Student Medical Release for the 2023 Spring Break trip to OKC

Student Information

Student Name(Required)
MM slash DD slash YYYY
Home Address(Required)

Contact Information

Mother Name
Father Name
Emergency Contact Name(Required)

Medical History

Month/Year
Does student have...
If "yes" please explain in accompanying box.
Is student subject to...
If "yes" please explain in accompanying box.
Medication(Required)
If necessary, you have permission to give my youth:
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
Please provide a picture of your medical card.