Youth Camp Registration Form (Page 3 of 4) in pdf

UC Irvine – Campus Recreation

Youth Programs

Medical Consent Form

I (we), the undersigned parent(s), or legal guardian of (Name of Child) ________________________, do hereby request that he/she be

permitted to attend the UC Irvine Campus Recreation Youth Programs and should the need arise, do hereby authorize and consent to any

x-ray examination, anesthetic, medical or surgical diagnosis and treatment rendered under the supervision of a licensed physician. It is

understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to

provide authority and power to render care which the licensed physician in the exercise of his/her best judgment may deem advisable.

It is understood that, if possible, effort shall be made to contact the undersigned prior to rendering treatment but that any of the above

treatments will not be withheld if the undersigned cannot be reached in a timely manner. I (we) will not hold liable the Regents of the

University of California, its officers, employees, or agents for medical aid or first aid rendered and will be solely responsible for all medical

or other expenses incurred in the care of my child.

I authorize release of information on this form to any licensed physician, hospital or medical staff member involved in the treatment or care

of my child.

Parent/Guardian Name (Print): ______________________________________________

Parent/Guardian Signature: _________________________________________________

Medical Information:

Emergency Contact _____________________________________________ Phone _____________________

Current Medications ________________________________________________________________________

Pertinent Medical History ____________________________________________________________________

Allergies _________________________________________________________________________________

Insurance Information (Required)

Insurance Company ________________________________________________

Policy Holder Name ________________________________________________

Policy Number ____________________________________________________

Parent/Guardian Release

I am the parent or legal guardian of ___________________________ and I have read and understood and agree to the terms and

conditions of this application and I am signing this release on behalf of said minor.

Parent/Guardian Signature: ___________________________________________ Date: _________________

CAMPER PICK UP AUTHORIZATION

(Please list those authorized other than Parent/Guardian listed above)

Parent/Guardian Authorization Signature_____________________________________________________________________________________________

1._________________________________________________________________________________

Phone_______________________________

2._________________________________________________________________________________

Phone_______________________________

CAMPER RELEASE AUTHORIZATION (CHILDREN 12 AND OVER)

I Request UC Irvine Campus Recreation to allow my child to release him/herself at the end of camp.

Parent/Guardian Authorization Signature____________________________________________________________________________________________

Youth Camp Registration Form Page 3