Summer Camp Medical & Liability Release Form

I. Personal Information

Child's Name*

First Last

Birthdate*

Age*

Grade*

(M)ale/(F)emale*

Address*

Street Address City State ZIP Code

Parent or Guardian's Name*

First Last

Home #*

use all zeros if this does not apply, but you must have at least one phone number filled in

Work #*

use all zeros if this does not apply, but you must have at least one phone number filled in

Cell #*

use all zeros if this does not apply, but you must have at least one phone number filled in

Email*

Enter Email Confirm Email

II. Medical Insurance Information

(Please provide copy of insurance cards)

Insurance Carrier*

Policy Number*

Name of Policy Holder*

First Last

Copies of Insurance Cards

Drop files here or

Max. file size: 512 MB.

III. Permission to Receive Medical Attention

Name of Person Giving Permission for Medical Attention*

I give permission for my child to receive medication and emergency treatment in the event of illness or accident. I give the person(s) designated by South River Baptist Church to be counselor/chaperone for this event permission to make a decision concerning emergency treatment.

First Last

IV. Discipline

Name of Person Giving Permission for Discipline*

I would like to inform the leaders of this Summer Camp that I fully trust their judgments and decisions toward the well being of my child. I trust my son/daughter to adhere and abide by any and all rules set forth and decisions made by the counselors. If my child does not, I expect them to be disciplined without the use of physical force as deemed necessary by the person(s) designated by South River Baptist Church to be counselor/chaperone for this event.

First Last

V. Liability Release

Name of Person Giving Liability Release*

I hereby release South River Baptist Church, their staff, chaperones and counselors of any and all liability in the event that my child is injured or becomes ill while in their care.

First Last

Name of Person Giving Transportation Liability Release*

I am fully aware that my child will be transported to and from activities based on days and weeks registered and that there will be ample supervision. I understand in the unlikely event of an accident or emergency that my child will receive adequate care based upon the information given. I assume all risks, hazards and incidentals involved in the conduct of the activity. I do hereby release, indemnify and hold harmless Headwaters Christian Academy and South River Baptist Church from any and all loss, injury or other damage arising out of this activity. I understand that the child will be transported to and from the offiste activity and I also understand the inherent risks in any travel, and agree to waive any and all liability on behalf of the referenced organizations for those risks.

First Last

Signature of Parent or Gaurdian*

Date*

I. Personal Information

II. Medical Insurance Information

III. Permission to Receive Medical Attention

IV. Discipline

V. Liability Release

Share this:

Like this: