Summer Camp Medical Release Form printable pdf download

Summer Camp Medical Release Form

Basic Information

Child’s Full Name: ________________________________

Parent/Legal Guardian Name(s):

Home Phone Number:

Work Phone Number:

Cell Phone Number or Pager:

Emergency Contact Information: (MUST be completed)

Name:

Phone Number(s):

Relationship:

Medical Information: (MUST be completed)

Doctor/Clinic Name:

Phone Number:

Any allergies:

Any medications:

Is there any additional medical information we should know about your child?

________________________________________________________________________

Statement

I acknowledge that my child’s experience in the summer camp program at Endview

Plantation will be outdoors, often in direct sun with minimal shade, and around wooded

areas. I understand there is a chance of my child coming into contact with the following

hazards including (but not limited to): ticks, chiggers, poison ivy/oak, and bees. I further

acknowledge that the site and its staff are not responsible for any bug bites, sunburns or

possible illnesses that may result from my child participating in the outdoor activities.

My signature below authorizes the staff at Endview Plantation to request emergency

treatment for my child is the situation warrants and I am unable to be contacted.

____________________________

_______________________

_______

Name of Parent/Guardian (printed)

Signature of Parent/Guardian

Date

Summer Camp Medical Release Form