Free Medical Release Form
If you are under 18 years old, you must have your parent or legal guardian fill out and sign this medical release form, thank you. Name: ___________________________________ Birth Date: _________________ Parent/Guardian name: _____________________________ Address: ___________________________________________ City, State/ Zip code_______________________________ Phone (daytime) _______________ Evening________________ Emergency Contact Person ______________________________ Phone: Daytime &Evening _______________________ Insurance Company: ____________________ Policy#: _________ No physical examination is required. We ask that campers are well and free from contagious or infectious conditions. Please complete the following to assist us in maintaining your health: List any allergies: _____________________________ List any medications currently take: _______________ Do you have: _________Asthma ________ Hear Attack? I, _________________, do herewith authorize my child to participate in the Lien Ket Camp 2008 on the week of August sponsored by the First Vietnamese Baptist Church of Salt Lake City and the activities to take place in the camp. Activities including (but are not limited to) swimming, sports, hiking, campfire, game competitions, transportation in camp and/ or staff vehicles, and site seeing. I hereby release said First Vietnamese Baptist Church of Salt Lake City and it staffs from all actions participating in these activities. I do herewith authorize the treatment of my child at camp by a qualified and licensed camp nurse in the event of any accident or illness, and the transfer of my child for treatment to a medical facility is needed. I agree to assume all financial responsibility for all medical care that may be required in such an event. All possible effort will be made to contact parents/guardian in the event of an emergency requiring further medical treatment than is available at camp, before such treatment is initiated. I, the undersigned, have read this release and understand its term. I execute it voluntarily and with full knowledge of its significance. Signed: ____________________________________ Date: _______________ (Parent or Legal Guardian)