Official Medical Release Form

Medical Release Form/Permission to Treat
ALL students, regardless of age, must have this form signed by a parent/guardian prior to camp.

Important: Please Read

STEP 1

Student's First Name

Student's Last Name

Student's Date of Birth

Parent/Guardian Email

Parent/Guardian Phone

Student's Gender

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Student's SSN (last 4 digits)

Secondary Emergency Contact

Secondary Contact Phone

Relationship to Student

STEP 2

Please supply ALL of the following information.
Attach a copy of your insurance card (front and back) to expedite medical treatment.

Medical Insurance Company

Group Number

Policy Holder's Name

Policy Number

Medical Insurance Company's Address

City

Medical Insurance Company's Phone

Region/State/Provience

Family Physician's Name

Postal / Zip code

Family Physician's Phone

Upload Insurance Card

STEP 3

Physical Limitations (asthma, diabetes, allergies, etc.) and/or special instructions
(allergic to certain meds, rare blood type, wears contact lenses, etc.)
List ALL medication taken on a regular basis:

List All Medications Below

List ALL medications brought with you to Camp.
Prescription meds MUST have a pharmacy label and name of doctor.
Please bring them in a Ziploc bag with your name on it:

List All Medications Below

List all operations/serious injuries (including the date of each) within the past five (5) years:

List Injuries and Dates Below

Please Sign Below

I declare that the information I’ve provided is accurate & complete.

Official Medical Release Form

Important: Please Read

STEP 1

STEP 2

Please supply ALL of the following information. Attach a copy of your insurance card (front and back) to expedite medical treatment.

STEP 3

Physical Limitations (asthma, diabetes, allergies, etc.) and/or special instructions (allergic to certain meds, rare blood type, wears contact lenses, etc.) List ALL medication taken on a regular basis:

List ALL medications brought with you to Camp. Prescription meds MUST have a pharmacy label and name of doctor. Please bring them in a Ziploc bag with your name on it:

List all operations/serious injuries (including the date of each) within the past five (5) years:

Join Our Mailing List.

Please supply ALL of the following information.
Attach a copy of your insurance card (front and back) to expedite medical treatment.

Physical Limitations (asthma, diabetes, allergies, etc.) and/or special instructions
(allergic to certain meds, rare blood type, wears contact lenses, etc.)
List ALL medication taken on a regular basis:

List ALL medications brought with you to Camp.
Prescription meds MUST have a pharmacy label and name of doctor.
Please bring them in a Ziploc bag with your name on it: