Sample Permission To Treat printable pdf download

These samples are for example only. Please check with local legal counsel for wording and

concepts consistent with state law.

Sample Permission to Treat

I hereby give permission to the medical personnel selected by the camp director to provide routine health

care; to administer medications; to order X-rays, routine tests, treatment; to release any records

necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or

my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician

selected by the camp director to secure and administer treatment, including hospitalization, for the person

named above. This completed form may be photocopied for trips out of camp.

Signed____________________________________ Date_______________

Sample Permission to Administer Over-the-Counter Medications

I (parent) hereby give permission for Camp White Cloud to administer the following over-the-counter

medications if the nurse deems it necessary. Dosages will be administered according to directions on the

bottle unless a physician directs otherwise.

Tylenol®

Headache

Pepto Bismol®

Upset Stomach

Immodium AD®

Diarrhea

Ibuprophen®

Menstrual Cramps

Calamine Lotion or CortAid®

Poison Ivy

Signed____________________________________ Date____________________

Sample Release and Application for Exemption from Physical Examination

and Immunization Requirements

It is respectfully requested that ______________________ be exempted upon religious grounds from the

physical examination and all immunization requirements required for attendance at Camp

________________________. To the best of my knowledge and belief, s/he is and has been in normal

good health and is free from all communicable or contagious diseases.

Should __________ manifest any condition where there appears to be reasonable grounds for suspecting

the presence of a communicable or contagious diseases, I agree that a physical examination may be

performed. Also, I agree that if any such disease is found, ________ will comply with the regular

quarantine or isolation procedures of the camp and of the community.

It is further understood that, should an emergency arise, I will be notified immediately. However, in the

event that we cannot be located immediately, the authorities of the camp may take such temporary

measures as they deem necessary.

I release and forever discharge the camp and each and every one of its officers, directors, partners,

shareholders, employees, agents, insurers, affiliates, successors in interest, attorneys, or any other

person or persons associated with any or all of them or any variation in the name of any or all of them

who might be liable (the “Released Parties”) from all causes of action, suits, claims, demands, or any

other damages or costs associated with actions taken by the Released Parties relative to the health,

sickness, and treatment of ___________.

I further understand and acknowledge that I make this release in full accord and satisfaction of and in

compromise of any current or future disputed or alleged claims or causes of action relative to the health,

sickness, and treatment of ______________against the Released Parties.

I represent and acknowledge that I have read and understand this agreement and release and warrant

that all statements made herein are true to the best of my knowledge. I further warrant and acknowledge

that I am of legal age, legally competent to execute this agreement and release, and accept full

responsibility there for.

__________________

___________________________________________

Date

Signature

___________________________________________

Printed

_____________________________________________________________________

Address

City

State

Zip

Sample Permission To Treat

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