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PERMISSION FOR EMERGENCY MEDICAL TREATMENT
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CAMPER FIRST NAME: LAST NAME: MIDDLE INITIAL:
BIRTH DATE: SOCIAL SECURITY NUMBER: PHONE NUMBER:
EMERGENCY PHONE NUMBERS:
THE INFORMATION YOU PROVIDE ON THIS FORM TELLS US WHAT TO DO IN CASE YOUR CHILD BECOMES ILL OR IS INQUIRED WHITE AT THIS CAMP. WE NEED TO KNOW A PHONE NUMBER WHERE YOU CAN BE REACHED DURING THE DAY AND AT NIGHT. IF WE ARE UNABLE TO REACH YOU, WE ALSO NEED ONE OR TWO ADDITIONAL PHONE NUMBERS (THE CHILD'S OTHER PARENT, A RELATIVE, OR A CLOSE FAMILY FRIEND
FIRST PERSON TO BE CONTACTED
 		 RELATIONSHIP TO CHILD
 		 DAYTIME PHONE
 		 EVENING PHONE
 
FIRST PERSON TO BE CONTACTED
 		 RELATIONSHIP TO CHILD
 		 DAYTIME PHONE
 		 EVENING PHONE
 
FIRST PERSON TO BE CONTACTED
 		 RELATIONSHIP TO CHILD
 		 DAYTIME PHONE
 		 EVENING PHONE
 
MEDICAL INFORMATION:
PHYSICAL CONDITIONS, MEDICAL HISTORY, ALLERGIES, AND MEDICATIONS BEING TAKEN. IF YOUR CHILE IS SENSITIVE TO BEE STINGS PLEASE NOTE BELOW. YOU WILL RECIEVE ADDITIONAL INFORMATION TO BE COMPLETED BY YOUR PHYSICIAN. BE SURE TO INCLUDE ALL MEDICAL CONDITIONS THAT WE SHOULD KNOW ABOUT (CONCUSSIONS, SEIZURES, ASTHMA, ALLERGIES, TOILETING PROBLEMS, GLASSES, ETC.)
 
 
 
RESTRICTIONS ON ACTIVITIES:
IS THER ANY ACTIVITY THAT YOUR CHILD CANNOT DO AT THIS CAMP DUE TO A MEDICAL CONDITION? PLEASE LIST:
 
 
 

PERMISSION TO PROVIDE MEDICAL TREATMENT
AFTER REASONABLE ATTEMPTS TO CONTACT ME HAVE BEEN UNSUCCESSFUL, I GIVE PERMISSION FOR THE ADMINISTRATION OF ANY TREATMENT DEEMED NECESSARY BY:
PREFERRED PHYSICIAN: PHYSICIAN PHONE NUMBER:
PREFERRED DENTIST:

DENTIST PHONE NUMBER:
OR, IF THE PREFERRED PHYSICIAN OR DENTIST IS NOT AVAILABLE, BY ANOTHER LICENSED PHYSICIAN OR DENTIST, IN THE EVENT THAT URGENT CARE IS NEEDED, I GIVE PERMISSION FOR MY CHILD TO BE TRANSPORTED TO THE NEAREST HOSPITAL BY LIFE SQUAD. THIS AUTHORIZATION DOES NOT COVER MAJOR SURGERY UNLESS THE MEDICAL OPINIONS OF TWO LICENSED PHYSICIANS OR DENTIST, CONCURRING IN THE NECESSITY FOR SUCH SURGERY, ARE OBTAINED PRIOR TO THE PERFORMANCE OF SUCH SURGERY.
PARENT SIGNATURE DATE:
DO NOT SIGN THIS PORTION OF THE FORM IF YOU HAVE GIVEN PERMISSION FOR EMERGENCY MEDICAL TREATMENT:
I DO NOT GIVE MY PERMISSION FOR EMERGENCY MEDICAL TREATMENT OF MY CHILD. I DO NOT GIVE PERMISSION FOR TREATMENT BY A PHYSICAN, DENTIST, TRANSFER TO HOSPITAL, OR FOR MY CHILD TO BE TRANSPORTED BY LIFE SQUAD.

IN THE EVENT OF ILLNESS OR INJURY REQUIRING EMERGENCY TREATMENT, I WISH THE CAMP AUTHROITIRES TO TAKE NO ACTION OR TO:

 
PARENT OR GUARDIAN SIGNATURE DATE

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Camp Coordinator - Tracy Dendinger

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