Camp Omalley Medical Consent Form printable pdf download

Camp Omalley Medical Consent Form

CAMP O’MALLEY MEDICAL CONSENT FORM

Name of Camper: _______________________________________________________

I, as legal guardian of the above named camper, authorize the coaching staff and /or

designee of Forest Hills Central High School Football program to seek medical treatment

for my son as they see necessary at any nearby medical facility. I consent to any

treatment and hospital care deemed necessary by a licensed health care provider during

the camp session.

I understand that this authorization is given in advance of any specific diagnosis,

treatment or hospital care, and that it is given to provide the camp coaching staff

authority to seek medical treatment, and to provide a licensed health care provider the

authority to administer this treatment as deemed necessary to the above named child.

I accept responsibility for payment of all services rendered; I authorize any medical

facility rendering services to release medical information necessary for the processing of

insurance claims; and I authorize the payment of insurance claims directly to the medical

facility.

I understand that whenever possible, the Ranger Football Program staff will make a good

faith effort to contact me or an emergency contact person(s) before seeking treatment. If

this is not possible, I understand that the Program staff will notify me or my designee as

soon as possible of any and all diagnoses and treatments.

____________________________________________

(Signature of Consenting Parent/Guardian

Medical Consent is required before departure to Camp O’Malley. Please return this

printed form to Coach Rogers or send in by mail to:

Attn: Camp Registrar

P.O. Box 763

Ada, 49301

Camp Omalley Medical Consent Form