Day Camp Medical Release Form

Click link below for a word document version of this form.

Day camp medical release form 2013

Registration Form 

1st & 2nd Grade Day Camp – July 29th, 30th, & 31st, 2013

(Circle One)

Youth: YSmall,   Ymed,   Ylarge

Adult size: S     M      L XL      XXL     XXXL

Name of person attending camp: ____________________________________________________

School Grade Completed_________ Sex (circle one) M  F

Age________ Birth date________________

Sponsoring Church:  ______________________________________________________________

Parent or Guardian (of minor ) _______________________________Home Phone  _____________

Address___________________________________ City_______________ St______ Zip________

In case of emergency notify: ____________________________ Relationship__________________

Emergency phone numbers: Day_____________ Night______________ Cell __________________

Physician’s Name_____________________ (Imperative if your child has allergies.) Phone____________

List any allergies to medications or any known allergies________________________________________

_____________________________________________________________________

Date of last tetanus immunization________________ List medications presently being taken: _________________________________________________________________________

_________________________________________________________________________

Medical Insurance Company__________________________ Insurance Policy #___________________

(This above information is needed in case your child or the sponsor has to taken to the hospital and the

parent/guardian cannot be reached.)__________________________________ Date________________

Signature of Parent /Guardian/Sponsor

AUTHORIZATION FOR EMERGENCY CARE TO A MINOR

I/we the undersigned, parent(s) or legal guardian of the minor (name)_____________________________

(birthday)________________, do hereby authorize any X-ray examination, anesthetic, dental, medical, or surgical diagnosis or treatment by any physician or dentist licensed by the State of Oklahoma and hospital service that may be rendered to said minor under the general, specific or special consent of: ______________________________________

(Name of adult sponsor who is temporary custodian of minor)

It is understood that this consent is given in advance of any specific diagnosis or treatment being required,   but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise his/their best judgment as to the requirements of such diagnosis or medical or dental or surgical treatment.

Date________________ Parent /Legal Guardian____________________________________________

AUTHORIZATION FOR MEDICAL INFORMATION RELEASE

I hereby authorize the hospital to release the following information contained in its hospital records to the representative of the Tulsa Metro Baptist Association concerning Diagnosis, prognosis for

_____________________________________________________ Date of birth ____________________

Name of Camper/Sponsor

This information will be used for insurance billing.  ________________________________ Date _______                                                                                                Signature of Parent or Guardian/Sponsor

 

Please make sure you have one (1) ORIGINAL and  one (1) copy of each registration form.

ORIGINAL (1) copy to registration at Kamp.   CHURCH keeps one (1) copy