Youth Medical Release Form

This release form is mandatory for any Conference attendees under 18 years of age. Please fill out
the form as completely as possible and present it at the time of registration or check-in for the Conference.

I hereby permit any member of the Spiritual Assembly of Los Angeles, CA or any
sponsor of the "Spiritual Decendants of the Dawn Breakers" Conference to obtain medical
treatment for my child in case of illness or injury.

Please Print Legibly

Full name of youth: __________________________________________________________

Name of parent or guardian:____________________________________________________

Signature of parent or guardian:________________________________________________

Please list any allergies to medications or any other allergies that may require medical attention in case of
exposure:

________________________________________________________________________

________________________________________________________________________

Please list any prescription medications your child will be taking during the conference:

________________________________________________________________________

Emergency Contact Information:

Full Name:________________________________________________________________

Relationship to youth:_________________________________________________________

Phone #: (_____) ______ - _________ Home Cell Work

INSURANCE INFORMATION:

Name of carrier:________________________ Carrier policy #:_______________________

Any additional information:

_______________________________________________________________________

________________________________________________________________________