Permission For Information And Emergency Treatment Form printable pdf download

Summer Camp

Permission for Information and Emergency Treatment Form

Full Name

________________________________________________________________________

(first, middle, last)

Gender (Circle):

Grade: __________

Parent or Guardian with whom student resides:_______________________________________________________

Address____________________________________________ City _______________, GA Zip _______________

Mother’s Phone: Home __________________ Cell ____________________ Work ___________________________

Father’s Phone: Home __________________ Cell _____________________ Work ___________________________

E-mail: Mother ___________________________________ Father _______________________________________

Physician Information

Name __________________________________________________ Phone _______________________

Emergency Contact Information

Please list 2 people to contact if we cannot reach parents.

Name_________________________________________________________ Relationship ______________________

Phone: Home _________________________ Cell __________________________ Work _______________________

Name_________________________________________________________ Relationship ______________________

Phone: Home _________________________ Cell __________________________ Work _______________________

Insurance Information

Policyholder’s ID Number____________________________ Employer _____________________________________

Group Name_______________________________________ Group Number _________________________________

Effective Date ____________________

Insurance Company ____________________________________________________________________

Address_________________________________________ City __________________ State _____ Zip ____________

Phone:__________________________________________________________________________________________

Preferred Hospital/Emergency Room__________________________________________________________________

Medication Information and Permission

Please list all current medications, allergies and treatments required:

______________________________________________________________________________________________

(check box for “yes”):

Asthma Inhaler

Epi-Pen

If your child uses an inhaler or epi-pen, please bring the first day of camp and give to the camp staff with your child’s

name on every item. Camp Staff will maintain asthmas inhalers/epi-pens in emergency packs.

Permission For Information And Emergency Treatment Form