Coerver Medical Release Form
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1MEDICAL RELEASE FORM
COERVER® Coaching of Colorado
P.O. Box 4946
Englewood, CO 80155
E-MAIL: coervercolo@comcast.net
Camper Name
Date of Birth_____
Street, City, State & Zip ________________________________________________
Home Phone
Business Phone
Cell Phone _____
Emergency Contact Person
Phone _________
My Insurance Company is: _____________________________________________
Policy or Group Number:_______________________________________________
Our Physician is:
Phone__________
Should the Camper be restricted in any way? Please describe in the space below. __
__________________________________________________________________
__________________________________________________________________
Medications which Camper is bringing to Camp: ____________________________
__________________________________________________________________
__________________________________________________________________
I hereby grant my permission to administer, and accept any financial responsibility for
any and all medical attention necessary to be administered to my child/ward, in the
event of an accident, injury, sickness, etc., while attending the Coerver Coaching
Camp. Any representative of the Coerver Coaching Camp is designated to act in my
behalf until I have been contacted.
SIGNATURE (Parent/Guardian)
_________________________________
Coerver
Coaching
of
Colorado
P.O.
Box
4946
Englewood,
CO
80155
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