Medical Release Form / Permission To Treat (Page 2 of 2) in pdf

List ALL medication taken on a regular basis and/or any brought with you to Camp. (Prescription

meds MUST have a pharmacy label and name of doctor.)

______________________________________________________________________

List all operations/serious injuries and dates within the past five (5) years:

______________________________________________________________________

The Health History is correct so far as I know, and the person herein described has

permission to engage in all prescribed activities except as noted.

Emergency Authorization - I hereby give permission to medical personnel selected by the

participant s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for

myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I

hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper

treatment, order injections and/or anesthesia and/or surgery to myself as named above.

I further authorize the release of the above medical information to appropriate medical

personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release

the church, its employees or agents from liability associated with participation in a church activity.

I understand that if I do not have medical insurance, I, as the parent or guardian, will be

responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved in taking place in recreation activities and other

activities related to participation in youth functions.

Signature of Parent/Guardian ___________________________ Date ____________________

The following should be completed by the notary witnessing parent/guardian s signature.

The State of _________________________ the County of________________________ Before me, a

Notary Public, on this day personally appeared ____________________ known to me (or proved to me

on the oath of__________________________________) to be the person whose name is subscribed to

the foregoing instrument and acknowledged to me that he executed the same for the purpose and

consideration therein expressed. Given under my hand and the seal of the office this

_______________day of ___________________, A.D.______________________.

Notary Public, Signature __________________________

My commission expires the _________ day of______________, A.D.______________.

Medical Release Form / Permission To Treat Page 2