YouthCamp 2003 Medical Consent Form

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Covenant Fellowship Church August 14-17, 2013 Camp Ladore Information put on this form will be kept strictly confidential and will be shared with YC pastors, administrators, and team leaders at the discretion of camp medical staff. This ensures safety and the welfare of each person attending YouthCamp

Personal Information: Date of Birth

Camper/Child/Adult name Male

Female

Home Address State

City

Zip Code Phone Number

Parent (or guardian): Home Address (if different from above) State

City During camp we expect to be:

Home

Zip Code YouthCamp

Emergency Contact:

at this number

Relationship:

Phone Number Address (if different from above) State

City

Zip Code

Insurance Information: Is the individual covered by family medical/hospital insurance Who is the carrier or what is the plan name? Group Num: Name of policy holder

Relation

Medical Information: List all known allergies (medications, food, asthma, insects, etc) please describe allergic reaction and treatment Please check medication(s) that can be taken at camp: Advil

Tylenol

Benedryl

Pseudofed

Pepto Bismol

Medications being taken: Please list any and all medications (including over-the-counter or nonprescription drugs) being taken regularly. Bring enough medication to last the entire week of camp. Please plan on turning in all medications to the camp nurse when you check-in at YC. The camp nurse will hold and distribute all medications. Please keep the medications in the original package or bottle. This individual takes no medications regularly This individual takes medications regularly Medication:

Dosage:

Times taken daily

Medication:

Dosage:

Times taken daily

Any medications that are usually taken during the school year, but are not taken during the summer?

General Questions (explain the "yes" answers below) Has/does the individual: Had any recent injury, illness, or infections disease?

Ever had a head injury or been knocked unconscious

Have a chronic or recurring illness/condition?

Ever had any problem joins (knees or ankles)?

Ever been diagnosed with a heart murmur?

Ever had frequent ear infections?

Had mononucleosis in the past 12 months?

Ever had seizures?

Ever been hospitalized?

Ever had high blood pressure?

Have frequent headaches?

Have diabetes? Have asthma?

I don't know

Date of last tetanus shot? Please provide any additional information about the individual's health or physical restrictions that will help the Covenant Fellowship staff to provide the best possible care.

I, the parent/guardian, assure that this health history is correct and complete to the best of my understanding. The individual attending camp has my permission to participate in all camp activities unless otherwise noted. I also grant permission for the above named child to be treated if any medical emergency, illness, or injury arises. In granting this permission, I accept all moral, legal, and other responsibility for the above named child; and in so doing, I relieve Covenant Fellowship Church and its employees from all responsibility other than that of proper adult supervision. I also grant permission for a licensed doctor, physician, licensed registered nurse, emergency response team at camp, or emergency treatment center selected by the camp directors to administer the necessary attention and aid IMMEDIATELY to my child should he or she become injured or sick during the dates of August 14-17, 2013, and to do so without having to wait until we are contacted. We consent to any X-rays, examination, anesthetic, medical or surgical diagnosis, treatment, or hospital care. We understand the camp administrator will endeavor to reach us should the nature of the injury or illness warrant it. Parent/Guardian/Adult signature

Date

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