Summer Camp Medical Release Form (Page 2 of 3) in pdf

Summer Camp Medical Release Form Page 2

Does your child have a diagnosis, if so, please explain:

_____________________________________________________________________________________

In case of emergency if you have a hospital preference please list:

_____________________________________________________________________________________

I authorize and direct the The Muse Knoxville to call a doctor or other medical

personnel and to obtain or provide such other medical services as the The Muse

Knoxville, in its sole discretion, deems necessary or appropriate in the event of an

accident or sickness affecting my child. I shall be solely responsible for paying all

expenses incurred with respect to any such accident or sickness.

Initial________

Except as set forth above, I certify that my child is in good health and can participate in

all normal activities of the group.

Initial________

I understand that reasonable measures will be taken to safeguard the health and

safety of the children and that The Muse Knoxville will notify me as soon as reasonably

possible in case of any emergency affecting my child. However, in the event that an

accident or sickness occurs concerning my child, I will hold harmless and release the

The Muse Knoxville, the Board of Directors, the staff of The Muse Knoxville and the City of

Knoxville from all liability concerning such accident or sickness.

Initial________

Parent/Guardian Signature and Date

___________________________________________________________Date_____________________

Summer Camp Medical Release Form Page 2