Adult Release Of Liability And Medical Consent Form printable pdf download

a ministry of The Free Methodist Church in Southern California

Adult Release of Liability and Medical Consent Form

Page 1 of 2

In order to comply with state laws we ask for the following Health History/Medical Consent Form to be completed and

signed by each person over the age of 18 attending OGCCC. Please be aware that OGCCC does NOT provide medical

or hospital insurance coverage.

Name __________________________________ DOB ____________ Gender ____________ Ht _________ Wt _________

Address _________________________________________ City _____________________ State ________ Zip ___________

Home Phone _______________________ Work Phone _______________________ Mobile Phone _______________________

E-Mail _____________________________ Date(s) at OGCCC __________________ Name of Group _____________________

Status: Cabin Leader

Camper

Emergency Contact _______________________________ Phone _______________

I understand that my photo may be taken at camp and authorize OGCCC to post these photos on the Oak Glen web site

or use them in other materials to promote Oak Glen Christian Conference Center.

I do not wish to receive any OGCCC promotional materials in the future.

Medical Information:

Are you covered by medical/hospital insurance? Yes

Insurance Carrier _______________________________________________________ Policy # ___________________________

Name of Responsible Party _____________________________________________ Social Security #_____________________

Address __________________________________ Phone __________________ Relationship to Camper_________________

Name of Family Physician _______________________________________________ Phone ____________________________

Date of Last Tetanus Shot ____________ Are all immunizations up to date? Yes

If no, please attach explanation

Has Camper recently been exposed (within last 3 weeks) to any kind of communicable disease? _____________________

Because of the terrain, altitude, and program involvement, OGCCC is not designed to accommodate and may not

provide a safe camp experience for those with special needs. If you have ANY chronic condition, including any of the

following: Asthma, Bleeding/Clotting Disorders, Cardiac Problems, Diabetes, Emotional Handicap, Epilepsy, Nervous

Disorder, Physical Handicaps, Seizure Disorder, or require injections of any kind, notify your group leader and ask if

your group has the level of medical supervision required for your condition(s). If a guest with special needs comes to

OGCCC without appropriate medical supervision, the group or party may be asked to return the guest to his/her home.

PO Box 1580, Wildomar, CA 92592

909-797-2570

Adult Release Of Liability And Medical Consent Form