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:  
Is   y our   c hild   a llergic   t o:  
_______Bee/Wasp   S tings   _______Pollens   _________Medications       _ ______Hay/Straw         _ ______Penicillin  
If   a llergic   t o   m edications   p lease   l ist   t he   n ame   o f   t he   m edications:
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?  
    I modium____________     A dvil__________     M ylanta_________  
Dramamine   ( for   n ausea)   _ _______  
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  
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 )  


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