Summer Camp & Conference Health Consent Form 2018
Please provide a copy of your insurance card for verification purposes when your child goes to camp. The following information is required to ensure that your child’s individual needs are met while attending camp. Information is confidential and will be made available only to those people who are directly responsible for your child’s well being. In the event of an emergency, every effort will be made to contact the parent or designated individual. No person under 18 will be allowed to attend camp without a completed health form. Many hospitals require signatures before proceeding with treatment. INSURANCE: The Christian Church in Indiana has insurance that covers only accidents that occur at camp.
NOTE: Family insurance is the primary insurance. The region is the secondary insurance.


By signing this form you agree that as parent/guardian of your minor child, you do hereby delegate to a representative of the Christian Church in Indiana authority to consent to all health care (x-rays, routine test, hospitalization, injection, anesthesia and/or surgery if necessary) to be rendered to the named minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the state of Indiana. This authority is delegated due to my/our unavailability to exercise the authority in person. This delegation of authority will commence and end on the dates your child attends summer camp.

LIABILITY: The Christian Church in Indiana is not responsible for personal items that are lost, stolen, or broken at camp sites.

Email address *
Camper's Name *
Your answer
Parent/Guardian Name *
Your answer
Address - street, city, state and zipcode *
Your answer
Camper's Social Security Number *
Your answer
Phone Number (s) *
Your answer
Emergency Contact (name, phone and relationship to camper) *
Your answer
Camper's Birth date *
Your answer
Camper's Heath Insurance Information - please list the Policy Holder's Name, Company name/phone and Policy/ID/Group Numbers *
Your answer
Is the camper in good health and able to participate in all normal camp activities? *
Date of last complete physical examination? *
Your answer
Date of last Tetanus shot/booster? *
Your answer
Allergic to any of the following?
Information Camp Director should have? And explain any of the above answers in this space:
Your answer
If camper is on any regular medication, state drug and dosage to be administered
Your answer
Medications brought to camp must be in their original container which lists proper dosage and frequency. I give permission for first aid director to administer over-the-counter drugs (ie.: Tylenol/Sudafed) as needed to this camper.
I agree to permit my camper to be transported in private or public vehicles while at camp *
I agree to give permission for my camper to be used in camp publicity *
Signature *
Your answer
Date *
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