For Office Use Only: Med Conditions Rx’s/Restrictions Allergies __________________ __________________
Box N-3199 * Nassau, Bahamas 1811 NW 51st ST. * # 1165 * Ft. Lauderdale, FL 33309 (954) 681-4692 (U.S.) * (242) 323-6202 (Bahamas) Fax: (242) 356-3712 (Bahamas) E-mail: evangelistkselver@hotmail.com
2009 MEDICAL AND LIABILITY RELEASE (RETURN WITH PARENT’S SIGNATURE ASAP) CAMPER’S NAME ___________________________________________ AGE_______ Please PRINT Last Name
First
M
F BIRTH DATE________
ADDRESS________________________________________________________________________________________ Street, City, State/Province, Zip, Country
IN EMERGENCY, NOTIFY (NAME) ___________________________________________________________________
Relationship to Camper
PHONE: (_____)___________________ Home
(_____)____________________
(_____)___________________
Work
Cell
FAMILY DOCTOR: _________________________________________ DR.’S PHONE: ___________________________ CHURCH NAME: ________________________________________________ CAMP DATES ___/___/___ - ___/___/___ DATE OF LAST PHYSICAL EXAM____________ T-SHIRT SIZE: Youth Sizes _______
M
L
HEALTH HISTORY—CONFIDENTIAL Last Tetanus Shot ___/___ Swimming Restrictions? Y/N Heart Condition Bedwetting
Adult Sizes:
S
M
L
XL
XXL
WAIST SIZE (GIRLS ONLY)
Allergies: Drugs/Insect Stings/Food Asthma: Nebulizer? Y/N Diabetes: Insulin Dependent? Y/N Physical Handicap Epilepsy/Seizure Disorder Nervous/Mental Disorder Other (please specify) ________________________________________
Please describe any condition listed above in the space provided. Prescription medications in original labeled containers must be checked by the Nurse/First Aid Provider at camp check-in. Note: Camp Elienai can only administer medication with written parental permission and specific instructions written below or on reverse of this form. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Medication(s) Name (Use Reverse Side if Needed)
Dose(s)
Times
If you have medical insurance, your carrier will be billed for medical charges in case of illness while at camp. Do you want to use the camp’s insurance (British American)? Yes No Do you have medical insurance? Yes No
Please complete information below and attach a copy of both sides of any insurance cards: Primary Insured’s Name: ___________________________________________ Policy No.______________________ Insurance Company: ______________________________________________ Group No. ______________________ MEDICAL RELEASE In the event of an emergency during the camp dates as shown on this form, I hereby give my permission to the physician or dentist selected by Camp Elienai to hospitalize, to secure proper treatment and/or order an injection, anesthesia, or surgery for me as deemed necessary. I also authorize the first aid attendant on duty at Camp Eleinai to administer medical aid as required for illness or injury under a physician's orders. The signature of the adult below is intended to serve as a medical release.
_____________________________________________________________________ Date: _____/_____/_____ Parent or Guardian’s Signature (those 18 years or older may sign for themselves)
______________________________________________________________________________________________ Please PRINT Name
Relationship to Camper
Use of Personal Information/Photos: Camp Elienai reserves the right to include picture, videos, or other likenesses of you or your child in its promotional materials.
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