Microsoft word - app & medical release form 2011.doc

UPLIFT 2011
Camper Registration Form
Grade (entering):
T-Shirt Size:
CAMPER’S GENERAL INFORMATION
Session(Circle) (1)6/11-16(2)6/18-23 (3)6/25-6/30
Youth Group:
EMERGENCY CONTACT INFORMATION
Mother’s Info Name:
(or guardian)
Father’s Info Name:
(or guardian) Address:
Youth Min./
Sponsor Info
Emergency
Contact (if above
B:____/____/____Age: ( ) You are unreachable)
INSURANCE INFORMATION
CAMPER’S HEALTH HISTORY
(PLEASE ATTACH ANOTHER SHEET IF YOU NEED MORE SPACE)
Date of last Reaction you
Type of Allergy
Usual treatment for a reaction
reaction
Allergies:
e:_____________M Immunizations
List any medical/psychological/social problems
Date of Diagnosis/Onset
Recent Surgeries
Recent (or significant) Hospitalizations or ER visits
age 1 of 2 Last Updated December 15, 2005-KV ~ ~ ~ ~ ~ →Please go to next page → ~ ~ ~ ~ ~
Continued from page 1
List all meds
Name of Medication
The following over-the-counter medications are stocked in the Uplift health station. Please circle any meds you DO NOT wish your child to receive (if any):
Pain Relievers
Gastrointestinal Meds
Allergy/Itch/Cough Meds
Azo (phenazopyridine HCl) – For pain from UTIs Eye drops (naphazoline HCl, pheniramine maleate) Chloraseptic lozenges/spray (benzocaine, menthol) Ear ache drops (chamomil a, mercurius, solubilis sulphur) Mylanta Midol (Tylenol+caffeine+pyrilanine maleate) Topical Wound Ointments
Pamprin (Tylenol+pamabrom+pyrilanine maleate) Feminine Products
Miscellaneous
Please list any other information that may be helpful to the Uplift medical staff.
Medical Release Statement
I ___________________________ (print name) consent to the above-named student to participate in Harding’s Uplift. I further authorize Uplift personnel to sign documents permitting the performance of medical assistance as deemed necessary by legal y licensed medical personnel at the time of il ness or injury to the above student and wil accept the financial responsibility for said medical assistance.
Signature of parent/guardian: Date:
Tuition for Uplift depends on when you register. If you register online and your deposit is
postmarked by April 11, 2011, you will pay $210. If you register and pay your deposit after that
date, the tuition will be $225. The tuition includes a $100.00 deposit/registration fee. The
$100.00 deposit is refundable until May 1, 2011. After May 1, 2011, the deposit is non-
refundable, but it may be transferable in some cases in the event of cancel ation for any reason.
You are not official y registered for Uplift until your deposit is received and you register online.
You must also send this form in. You wil be notified within one week of your acceptance into
Uplift. Tuition fees include meals, camp/recreation activities, and T-shirt. No extra money is
needed except for personal items. Campers will not be permitted to attend Uplift if both
pages of this medical release form are not completed in full.
I __________________________ (camper’s printed name) agree to fol ow al of the guidelines
of Uplift and Harding University and wil cooperate and participate in al of its activities. I
understand that the dress code policy begins when I leave my home for Uplift, and it ends when
I get home.
Signature of Camper: Date:
Page 2 of 2 Last Updated December 15, 2005-KV

Source: http://www.snellvillecofc.org/clientimages/51212/documents/uplift%20application%2011.pdf