Microsoft word - camper medical info and release form.doc

Please use a separate form for each camper. Camper Name ____________________________ Age _______ Boy Girl Home Address __________________________________________________ City _____________________________State ________ Zip _____________ Telephone: Home _(____)______________ Other_(_ __)__________________ Each Camper must be immunized against the following: Polio, Measles, Rubella, Diptheria, Whooping Cough, and Tetanus. Date of most recent Tetanus Shot ______/_______/__________ List any regular medications: List any allergies (medications, food, insect bites, environment, etc.) NOTE: If health history shows physical limitations or restrictions for rigorous camp activities, your camper is required to have a doctor’s written permission for participation indicating any limitations. Family Physician ___________________________________ Phone __________________ Family Dentist ____________________________________ Phone __________________ Medical Insurance Co. ____________________________________________ Policy # ________________________ Phone _____________________ Over-the-Counter Medications: Shiloh Family Ministries will not dispense “over-the-counter” medications without the expressed written authorization of the parent or guardian. If it is your desire to authorize SFM employees or volunteers to dispense such medications to your minor age child, please place a check mark beside each medication listed below that is approved for dispensing. If spaces are left blank, SFM WILL NOT dispense that particular medication unless a physician or parent/guardian is contacted for approval. _____Acetaminophen (Tylenol) _____Antihistamines _____Multi-symptom Cold Meds Page 1 of 2 Parent/Guardian Initials____________Date___________ Notary Initials____________ Date___________ I hereby give permission for medical attention to be administered to my child, who is a minor, by those agents or agencies designated by Shiloh Family Ministries (SFM). Where my child is a minor, I authorize SFM to administer to my child those “over-the-counter” medications specifically noted above according to the prescribed directions for each. I agree to waive, hold harmless, and release Shiloh Family Ministries, its employees, and volunteers from any claim or course of action that might arise on behalf or myself, or my child who is a minor, as a result of my or his/her participation in the camp activities, other than a claim for the willful, wanton or reckless misconduct of Shiloh Family Ministries, its employees or its volunteers. Printed Name of Parent/Guardian________________________________ Parent/Guardian Signature ____________________________________ Emergency Phone ___________________________ Date________________ The foregoing instrument was acknowledged before me this _______ day of ____________________, 20______. By _____________________________________, who is personally known by me or who has produced a ___________________________ as identification. _______________________________ Signature of Notary Printed Name of Notary My Commission expires _______________________ Page 2 of 2 Parent/Guardian Initials____________Date___________ Notary Initials____________ Date___________

Source: http://shilohfamilyministries.org/Camper_Medical_Info_Form.pdf