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Microsoft word - medical consent form.docx

(to be filled out by parent or guardian) 1145 James River Road - Scottsvil e, Virginia 24590 - Phone (434) 286-4403 - Fax (434) 286-3549 www.watermarkscamp.com
Name: _____________________________________ Dates Attending: _______________________________ Address: ____________________________________________________ State: _______ Zip: ______________ Date of Birth: _____________ Age: _______ Entering Grade: _____ Gender: _____ Male_____Female Did you come as an individual or with a group? _______ Individual ________ Group Name of Group: ____________________________________________________________________________ PARENT/GUARDIAN (if under 18 years of age): Name: __________________________________________________ Home Phone: ______________________ Mother’s Daytime Phone: ___________________________ Cel Phone: _____________________________ Father’s Daytime Phone: ____________________________ Cel Phone: _____________________________ Health/Medical Problems: ___________________________________________________________________ Drug/Food/Other Al ergies: ___________________________________________________________________ Last Tetanus: _________________ Regular Medications: __________________________________________ Activity Restrictions: ________________________________________________________________________ Special Diet Needs: _________________________________________________________________________ Family Doctor: ___________________________________ Phone: ___________________________________ Insurance Name: ________________________________ Phone: ___________________________________ Policy Holder: ___________________________________ Birthdate of Policy Holder: _____/_____/______ Policy #: ___________________________________________________________________________________

Watermarks Has Permission to Administer:
_______ Ibuprofen ______ Tylenol ______ Benadryl ______ Neosporin/Triple Antibiotic Ointment

Name: __________________________________________ Phone: __________________________________ The undersigned hereby acknowledges that the program(s) in which I have enrolled my child(ren) involves physical activity and exercise that carries some inherent health risks and risks of injury and I hereby assume those risks in enrol ing my child(ren) in the program. I understand that my child(ren) may be transported by bus, van or automobile to locations off the Watermarks campus as part of the program activities, and I hereby give my permission for my child(ren)’s transportation. I also grant permission for my child(ren) to receive emergency medical attention should I not be able to be contacted in a timely fashion. _______________________________________________ ___________________________________ Parent/Guardian Signature
By signing below, I grant permission for my child to participate in activities provided by and located at Watermarks
Camp. If I do not wish for my child to participate in any activity, it is my responsibility to inform my leader or
Watermarks Camp prior to my child’s arrival.

_______________________________________________

If there are any activities that are known that the parent does not want their student to participate in or any prior injuries that could limit students activities or experience please state below: __________________________________________________ Activity Restriction/Injuries
I, the undersigned, do hereby consent to the use by Watermarks Camp of my child’s image or

voice in any video, photograph or audio tape used for fundraising, advertising, publicity, or any
other purpose on behalf of Watermarks Camp. I also confirm that Watermarks Camp and staff

are not responsible for loss or damage of any personal items brought to camp. After campers
are registered and confirmed by deposit, there are no cancellations or refunds.

_______________________________________________

Source: http://www.cornerstone.ag/pdf/MA_Medical.pdf

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