Medical Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Medical Form

Email *

Camper Name *

Date of Birth *

YYYY

Street Address *

City *

State *

Zip *

Primary Parent Name *

Primary Parent Phone number *

Secondary Parent Name

Secondary Parent Phone number

Alternate Emergency Contact Name *

Name, Phone, Relationship

Alternate Emergency Contact Phone Number *

Name, Phone, Relationship

This camper will be attending the following camps: *

Boy's Adventure Camp Norcal

Boy's Adventure Camp Socal

Girl's Adventure Camp Socal

Father/Daughter Camp

Father/Daughter Canoe

Trinity White Water Canoe

Scuba

Coding Camp

Rock Climbing

Surf

Base Camp - Canoe

Base Camp - Backpacking

Base Camp - Mountain Biking

Base Camp - Sailing

Required

Camper Health Insurance Information *

Provider name, phone number, address, as well as any group or membership numbers. N/A if not applicable.

If any medications must be taken, please list them here:

Include any specific instructions. All prescription and over the counter medications must be clearly labeled with camper’s name, in the original container, and turned in during registration. N/A if not applicable.

Medications to Avoid:

N/A if not applicable.

This camper is currently experiencing or has problems with:

ADD/ADHD

Allergies

Asthma

Bed Wetting

Diabetes

High temperature when ill

hypoglycemia

Poison oak sensitivity

Sleep Walking

Other:

Food Allergies requiring special accommodation:

Examples: Peanuts, Milk, Shell Fish, Celiac deasease etc. N/A if not applicable.

Potentially life threatening allergies:

Examples: Bee Stings, latex, etc. N/A if not applicable.

If there are any conditions which might make portions of the Camp activities difficult, please indicate here:

N/A if not applicable.

Immunizations Current? *

Yes

Medical Waiver

I, the undersigned, do hereby authorize Sequoia Brigade Camp as agents for me to consent to any X-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act or the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Permission is also given to camp staff, ambulance, paramedic, EMT or First Responder personnel to give first aid as needed. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required. It is given to provide authority and power on the part of aforesaid physician and/or first aid provider in the exercise of his or her best judgment. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California, and similar provisions in other states or countries. The above named camper has my full permission to attend Sequoia Brigade Camp and participate in all camp activities, except as noted below. I understand that in case of a medical emergency, every effort will be made to contact a responsible parent or guardian of the camper.

Signature (Or Parent Signature for Minors) *

This Constitutes your electronic signature.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms