Medical Form
Email address *
Camper Name *
Date of Birth *
MM
/
DD
/
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: *
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:
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? *
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
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