Summer Camp 2025 Emergency Medical Authorization Form

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

This form enables Women Writing for (a) Change to obtain emergency medical treatment for a minor in the event that your child becomes ill or injured while in our care when you cannot be reached. You may also refuse to grant this authorization.

This form must be completed and submitted prior to the beginning of camp.

Note: In an Emergency, WWF(a)C will call 911 and the parent/guardian/primary contact.

Email *

Legal First & Last Name of Camp Participant *

Camp Week(s) Your Child Will Attend *

June 3-7 Grade 7-9 Watering Our Souls

June 10-14 Grade 4-6 Stretching Our Imagination

June 24-28 Grade 10-12 What Our Bodies Know

July 8-12 Grade 7-9 Mapping Happiness

Required

Camper's Date of Birth Including Year *

YYYY

First & Last Name of Parent/Guardian/Primary Contact *

Cell & Email Address of Parent/Legal Guardian/Primary Contact *

Name of Secondary Contact *

Cell & Email Address of Secondary Contact *

Name ofThird Contact

Cell & Email Address of Third Contact

IMPORTANT MEDICAL INFORMATION concerning my child's medical history including allergies, medication being taken, any physical impairments, or limitations in movement or exertion.

Please provide details or state "None."

I agree that neither Women Writing for (a) Change, nor any persons involved in its programs shall be held responsible for injury, illness, or damages to the person or property of registrant while attending classes.
*

I agree.

To Grant Consent:
If reasonable attempts to contact the persons above are unsuccessful, I hereby give my consent for: (1) the administration of any treatment deemed necessary by the preferred physician or dentist, or, in the event the designated practitioner is not available, another
licensed physician or dentist; (2) the transfer of my child to the preferred hospital or any hospital reasonably accessible and (3) I further give consent to treatment of my child during transportation by available medical technician ambulance to a treatment facility.
*

I DO grant consent. (Complete follow-up questions to "Grant Consent."

I DO NOT grant consent. (Skip to "Refusal to Grant Consent.")

Name & Office Phone Number of Preferred Physician (if you grant consent)

Name & Office Phone Number of Preferred Dentist (if you grant consent)

Name of Preferred Hospital (if you grant consent)

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring as to the necessity for such surgery, are obtained before surgery is performed.

I understand. Checking this serves as my signature to grant consent.

Clear selection

Refusal to Grant Consent (Do Not Complete If You Granted Consent)
I do not give my consent to emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish Women Writing for (a) Change to take NO action, or to do the following:

Acknowledgement of Refusal to Grant Consent (Do Not Complete If You Granted Consent)

Checking this serves as my signature to refuse to grant consent.

Clear selection

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Women Writing for a Change.

Does this form look suspicious? Report

Forms