Medical Release Form
FOR: OLMC Summer Bible Camp
I (we), the undersigned parent(s) or guardian(s) of __________________________________ , a minor, do hereby authorize adult volunteers of OLMC Summer Bible Camp as agent(s) for the undersigned, to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital. I further release from any liability ___OUR LADY OF MT CARMEL PARISH,
OLMC Summer Bible Camp _ , any of its ministries or
leaders in the event of an accident en route, during and returning from the above mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence.
Date signed ___________________________________
Parent/Legal Guardian (print) _______________________________________________________________
Parent/Legal Guardian (sign) _________________________________________________________________
Address_________________________________________________
City ___________________________
Emergency Phone: Home (_________) ___________________
Work (________) _______________________________
Health Insurance Company _________________________________________________________________
Policy or Group Number ______________________________
Phone (________) ___________________
If parent/legal guardian is not available in an emergency, contact:
Name ______________________________________________
Phone (________) ___________________
Please list any allergies. Include medications, foods, etc. ________________________________________
___________________________________________________________________________
Does your child have any medical or special needs, including medications currently being used?
No ____ Yes ____ If yes, please explain. __________________________________________________
__________________________________________________
Doctor’s Name _______________________________________
Phone (________) _______________________________
Dentist’s Name _________________________________________
Phone (________) __________________
Date of last tetanus shot _________________________
Birth date _______________________________