Ryla District 5330 Medical And Liability Release Form

Download a blank fillable Ryla District 5330 Medical And Liability Release Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Ryla District 5330 Medical And Liability Release Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

RYLA District 5330
Medical & Liability Release Form
(Must be completed for all Campers)
Please Print
Student’s Name ______________________________________ Phone (
) ________________________
Address ____________________________________________ City_______________ Zip _____________
Emergency Contact ___________________________________ Phone (
) ________________________
Health Questionnaire
If YES to any question please provide details/information on the reverse side of this form:
Yes / No
Yes / No
Yes / No
Allergies: ____
____
Heart Condition :
____
____
Condition Restricting Activities: ____
____
Diabetes: ____
____
Behavior Disorder:
____
____
Physical Accommodations:
____
____
Asthma: ____
____
Bleeding Condition: ____
____
(wheel chair, Interpreter etc.)
Epilepsy: ____
____
Migraine Headaches:____
____
Stomach Problems:
____
____
Menstrual Problems: ____
____
Tetanus Current:
____
____
Has your child been under the care of a physician in the last 90 days?:
____
____
List all medications. All medication MUST be given to the camp nurse to be dispensed.
Medication Name
Dosage
Frequency
Medical Insurance Provider__________________________________ Policy Number ____________________________________
Insured’s Name___________________________________________________________________________________
Please complete if you do not have a medical insurance carrier.
I give my permission to use my credit card in the event I have no insurance carrier.
Credit Card: _____Visa _____MasterCard
Credit Card #__________________________ Exp________
Authorized Signature________________________________________________________________________
Medical Transportation, Activity and Photo Release
I give permission to Rotary District 5330, Thousand Pines and its agents to select transportation to a medical provider who may
provide proper treatment for, hospitalization of, order injections, anesthesia or surgery for my child as named above.
There are many inherent risks in a mountain camp experience. Camp activities include, but not limited to hiking, sports, games,
low adventure ropes course, rock climbing and dancing. There is the possibility of risk of physical injury or harm from participating
in these activities. I voluntarily elect to allow the above named to participate in activities and assume the risk of injury or harm that
could result from participation. On my own behalf and that of my personal representatives and heirs, I hereby release Rotary
District 5330, Thousand Pines, its officers, employees and agents from all liability from any injury or harm to my child (or minor)
from participating in any activity at Thousand Pines, whether the injury or harm is caused by accident or by negligence of
Thousand Pines or otherwise.
I give the health care provider(s) at Pine Summit permission to give over the counter medication and administer other treatment as
they deem necessary.
I hereby agree that Rotary District 5330 or Thousand Pines may use any type of audio and/or visual records of this program for its
promotional and/or commercial purposes without compensation to me.
I have read, understand, and agree to the above. If you have any questions or concerns, feel free to e-mail
the Director at .
Parent/Guardian Signature:
___________________________________________________________________________Date__________
______

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go