Lewis-Palmer School District #38 Sports Camp Medical Form/
Parental Release and Insurance Information
Note: Please print legibly in INK or type.
This form must be completed in FULL, including signatures of parent or legal guardian. Participants will NOT BE ALLOWED to participate without the completed medical and parental release/insurance form. A separate form must be completed for each camp that your child will attend.
Participant Name_________________________ Date of Birth______________________
Applies to camp selected for payment.
Medical History
Is the above named ALLERGIC to any of the following?
Medications – Insect bites – Foods – Other YES NO
If YES, indicate what and what protocol should be followed if they have a reaction _____________________________________________________ __________
Is the above named presently taking, or will be taking any medication during his/her stay at camp? YES NO
If YES, indicate what________________________________________________
Is the above named being treated for an injury or illness at this time? YES NO
Circle all of the following Immunizations that ARE up to date:
MMR Diptheria Tetanus Polio Pertussis-Whooping Cough
Does the above named have/had any of the following? Circle all that apply:
Rubella Measles Mumps Chicken Pox Pneumonia Diabetes Epilepsy Heart Condition
Other____________________________________
NOTE: If the above named individual has a history of serious illness and/or injury (i.e. heart murmur, surgery, epilepsy, etc.) a note from a licensed physician must accompany this form to insure that the individual may be cleared to participate in all camp activities.
I certify that the above named individual is physically fit and able to participate fully in the above indicated Lewis-Palmer School District Sports Camp.
Signature of Parent/Guardian_______________________________________________
Date__________________________
Parental Release & Insurance Information
I give permission to the above named to attend and participate in the selected Lewis-Palmer Camp.
Furthermore, I hereby grant permission to the camp staff to render preventative, first aid and/or emergency treatment that they deem necessary to my son/daughter’s health and well-being. In the event of serious illness, the need for major surgery, or significant accidental injury, I understand that an attempt will be made by the camp staff to notify the designated emergency contacts in the most expeditious manner possible. If said staff is unable to communicate with me, the treatment deemed necessary for my son/daughter’s health and well-being may be given.
I Hereby:
1. Certify, that to the best of my knowledge, the medical information requested is complete and correct.
2. Agree to assume all risk of personal injury my son/daughter may incur arising from participation in the above indicated camp, and understand that the sport indicated above involves the potential for injury.
3. Agree not to hold the staff responsible for any injury sustained by my son/daughter during participation at camp.
4. Agree not to bring suit against Lewis Palmer School District #38 and/or its staff for any injury my son/daughter may sustain.
5. Understand that if necessary, in the judgment of the camp, that outside medical, surgical, or dental treatment are used for my son’s/daughter’s health and well-being, that all such expenses shall be my responsibility.
6. Agree to accept any decisions made by the Camp Director in the termination of camp attendance due to my son’s/daughter’s unacceptable behavior as determined by the staff.
7. Authorize the camp staff to administer medications to my child (as prescribed by physician) as indicated on this form.
PLEASE BE ADVISED THAT IT IS IMPERATIVE THAT YOUR CHILD BE IN GOOD HEALTH WHEN ARRIVING AT CAMP. THE DUTIES OF CAMP PERSONNEL CANNOT INCLUDE PROVIDING MEDICAL CARE FOR CAMPERS ARRIVING AT CAMP WITH PRE-EXISTING CONDITIONS.
INSURANCE INFORMATION
Insurance Company NAME, ADDRESS & TELEPHONE
____________________________________________________________
Policy Holder’s Name__________________________
Policy Number_______________________ Group Number_________________________
Emergency Contact (You must provide a number or someone that can be reached during camp hours, whether it is the parent or a designated emergency contact):
Name_________________________________________ Relationship_________________________
Home Number____________________ Work Number_______________ Cell Number______________
Signature of Parent or Guardian_______________________________________________________
Date______________________
