Microsoft word - willow springs medical release.doc

MEDICAL RELEASE AND INFORMATION

I, _________________________________ (parent) give permission for
Please Print: If Volunteer write “volunteer” in camper Willow Springs Water Park staff or camp volunteer to seek medical name space. Separate forms must be completed for each
treatment (including hospitalization, injection, emergency dental care, or camper and volunteer.
anesthesia, etc) for my child, ___________________________________ Camper Name: __________________________________ in the event of an emergency if deemed necessary and release Willow Springs and any volunteers or sites affiliated with the camp from any Parent Name: __________________________________ liability against named child. I hereby release Willow Springs Staff, Address: ______________________________________ Camp volunteers, associated staff and organizations from any liability City: ______________________ State: ___ Zip: ______ from any injury, loss or damage to person or personal property and to hold them free and harmless from any claims, demands, or suits from damages arising from the giving of such consent during camp or during Emergency Name/Phone: _________________________ transportation to and from events. I understand that every attempt will be ______________________________________________ made to contact the person on this form prior to treatment. Camper/volunteer age: ______ Male or Female I, the undersigned have legal custody of the child named above, have read and agree to the above release, and give my consent for him/her to attend T-Shirt size (circle) YS YM YL YXL Other: ______ Signed: ______________________________________ Persons with approval to pick up child other than parent Date: ______________________________________ (must present ID) ________________________________ Health History:
List any pre-existing or current medical conditions: Rules and Guidelines:
(Example: ADHD, asthma, hearing loss, etc.) _______________________________________________________ _______________________________________________________ • No diving, flips or head first sliding _______________________________________________________ Name, dose, and times of any medications: (Example: Amoxil 150mg, 8a.m. and 8p.m.) _______________________________________________________ _______________________________________________________ _______________________________________________________ List any food, medication, or natural allergies and usual treatment. • Wear swimsuit or swimming clothes to camp (Example: Peanuts/epi pin, wasp stings/benadryl) • Bring dry play clothes and towel in bag to camp for _______________________________________________________ _______________________________________________________ _______________________________________________________ Failure to obey rules or drop off from 2:00–2:30 and pick YOU WILL BE NOTIFIED JULY 19-23 IF ACCEPTED up from 8:00-8:15pm are grounds for cancellation of

Source: http://www.sandstonedrive.org/willowsprings_regform2010.pdf