MEDICAL RELEASE FORM

Insurance Information:

Cardholder’s
Name _______________________________________________________________

Insurance
Company ______________________________________________________________


I.D. # ________________________ Group # _________________________


Care Card # ____________________________________________________


Allergies, medical conditions, medications etc.

______________________________________________________________

 
You are expected to bring any medications you might need during camp and to notify us in advance.

Date of last tetanus shot: _______________________

Doctor name and phone __________________________________________

Authorization is hereby granted to provide whatever emergency medical treatment is necessary and/or hospitalization is deemed necessary for my minor child.

Parent / Guardian signature: (For campers under 18 years old.)

____________________________________ Date: _____________


____________________________________ Date _____________
Youth signature