Medical Form 2018
The parent/legal guardian must fill out this form. ONLY the parent/legal guardian is authorized to do so.
Student's name: *
Your answer
Age as of June 1st, 2018 *
Required
Current Grade *
Required
Parent or guardian *
Your answer
Address *
Your answer
Primary Phone # *
Your answer
Mother's work phone # *
Your answer
Father's work phone # *
Your answer
Parent e-mail *
Your answer
Emergency contact name *
Your answer
Emergency contact phone # *
Your answer
Emergency contact's relation to child *
Your answer
Student's doctor *
Your answer
Doctor's phone # *
Your answer
Does your child take any medications? If yes, what? *
Your answer
Will your child bring any medications to camp? *
If child is bringing medication, what are the details?
Your answer
Is your child allergic to anything? *
food, bee stings, etc?
If yes, to what is your child allergic?
Your answer
Are there any other conditions the nurse should know about?
asthma, nose bleeds, etc?
Your answer
I give my son/daughter permission to participate in the June 2018 Raspberry Ridge String Camp, and allow the Chapel Hill Bible Church/Raspberry Ridge leaders permission to provide transportation for him/her as necessary, and to procure for him/her any necessary medical transfer and treatment in case of accident/illness. I agree to pay for all such treatment and to hold the Chapel Hill Bible Church and its representatives harmless from financial and legal liability. *
By typing my name below I am confirming that I am the parent/legal guardian. *
This will be considered your online signature.
Your answer
Today's date *
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