Medical Release Form 2017: Kings Day Camp
In case of serious accident or illness at Kings Day Camp, someone trained in first response will call the paramedics. This may result in your child being sent to the nearest hospital if further medical treatment is recommended. Parents or legal guardians will assume full financial responsibility for ambulance and medical expenses incurred on behalf of your child for such treatment.
Camper's name
Your answer
Age
Your answer
Parent's name
Your answer
Best Contact Number:
Your answer
Physician's Name and Contact information:
Your answer
Do you have a preferred local hospital?
Your answer
Does your child have any physical restrictions?
Your answer
Does your child have any dietary restrictions?
Your answer
If medications are needed, please dictate the name of the medication, dosage, time administered, start date, and end date
Your answer
Please indicate the possible side effects of the stated medication
Your answer
By signing below, this I hereby give my permission to any trained Kings Day Camp employee to look after the wellbeing of my child and administer any medication that they may need.
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of King of Kings Lutheran School. Report Abuse - Terms of Service - Additional Terms