Winter Mission 2018 Medical Release
Camper Information
Camper's First Name *
Your answer
Camper's Last Name *
Your answer
Camper's Date of Birth *
Your answer
Insurance Information
Name of Insurance Company *
Your answer
Group ID #
Your answer
Subscriber ID #
Your answer
Emergency Contact Information
Name of Emergency Contact *
Your answer
Emergency Contact Cell Phone # *
Your answer
PERMISSION AND RELEASE OF LIABILITY
I give permission for the camper named above to take part in the Joy of Living Camp Winter Mission Retreat on January 12-14, 2018. During this time, I give my permission to the staff of Joy of Living Camp to seek medical attention in the event of sickness or injury. I, in turn, agree to accept financial responsibility for any treatment necessary. I release the staff of Joy of Living Camp from liability in the event of injury except in
I have read and understand the "Permission and Release of Liability" statement printed above. *
Medication
* All medication must be in original packaging from pharacy or store
* Must be correctly labeled with the child's name and dosage
* Must be given to the Camp Director (or his representative) at the time of pick up or arrival
* Will be dispensed by the Camp Director (or his representative) at meal times and/or bedtime, as necessary
I am sending medications for my child to Camp:
Name(s) of medications, time(s) to be given, and dosage
Your answer
Submission
By typing my name and date below, and clicking the "SUBMIT" button, I am certifying that I am the parent or legal guardian of the above named child.
Name of person filling out this form: *
Your answer
My relationship to the camper named above: *
Your answer
Date: *
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Submit
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