Medical Release / Waiver Of Liability Form

Medical   R elease   /   W aiver   o f   L iability   F orm  

Camp   B eaverfork  

Camper   N ame:   _ ___________________________________________Birthdate:__________________________  

Parent/Guardian   N ame:   _ _________________________________________________________  

Phone:   _ ___________________Emergency   C ontact   N umber:   _ ___________________________    

Home     A ddress_________________________________________________________________  

  C ity___________________________State_______________________ZipCode_____________  

Insurance   C ompany:   _ ______________________________Policy   N umber:   _ ________________  

Campers   S oc.   S ec.   # _____________________   P arent/Guardian   S oc.   S ec.   # ________________________    

 

At   c amp   w ith   ( church   n ame)  

_____________________________________________________________________________  

Church   P hone   # _______________________Pastors   P hone   # _____________________________  

 

Please   a nswer   a ll   t he   f ollowing   q uestions   c oncerning   t he   a bove   l isted   c amper:  

1.

Is   y our   c hild   a llergic   t o:  

_______Bee/Wasp   S tings   _______Pollens   _________Medications       _ ______Hay/Straw         _ ______Penicillin  

_________Other  

 

 

If   a llergic   t o   m edications   p lease   l ist   t he   n ame   o f   t he   m edications:

____________________________________________________________________________________

____________________________________________________________________________________  

 

2.

May   o ur   m edical   p ersonnel   a dminister   t he   f ollowing   m edications   t o   y our   c hild   i f   n eeded?  

Tylenol_____________  

Benadryl_________  

    I modium____________     A dvil__________     M ylanta_________  

Dramamine   ( for   n ausea)   _ _______  

 

3.

Is   y our   c hild   b ringing   a ny   m edication   w ith   h im/her?   _ ___yes____no.  

  M edications   w ill   b e  

If   y es   w hat   i s   t he   m edication_______________________________________________.

administered   b y   t he   C amp   S taff.   Y our   c hild   m ust   g ive   h is/her   m edication   t o   t he   C amp   S taff   u pon   a rrival   t o   t he  

camp.  

 

4.

Does   y our   c hild   h ave   a ny   p hysical,   e motional,   m ental   o r   b ehavioral   c oncerns   o r   l imitations   t hat   o ur   s taff   s hould   b e   a ware  

of?   _ _____yes_____no.   I f   y es,   p lease   e xplain.  

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________  

(Continued   o n   P age   2 )