Medical Authorization Form

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Camp WPA Emergency Contact / Authorization Form.

Email *

Name *

Mothers Name, Phone Number & Email *

Father's Name, Phone Number, & Email

Student Medical Conditions *

Asthma

Chronic Cough

Nose Bleeds

Seizures

Allergies (seasonal)

Allergies (Food)

Allergies (all other)

NONE

Does your child have any reactions to the allergen checked above?

Do you give us permission to treat your child?

Yes

Clear selection

Do you give us permission to give your child acetaminophen for a fever if we are unable to contact you?

Yes

Clear selection

Emergency Contacts/ Phone Numbers. Please list 3 if possible.

Send me a copy of my responses.

Submit

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