Microsoft word - fusion2012medicalrelease.doc

Medical Release Form for Winter Camp 2012
Disciples Church Student Ministries
Please attach to this form a photocopy of your child’s medical/insurance card.

Student Name:
Check if Minor is Subject to Any of the Following:
Allergic Reactions:
Other allergies/comments pertinent to child’s health: This form authorizes a nurse or adult supervisor designated by Disciples Church to provide basic first aid, and to
administer over the counter medicines to the above student in the event of injury or illness. In the event of any injury or
illness unable to be treated by first aid or over the counter medicines, you will be notified and your child may be taken to
a nearby hospital or clinic for treatment if necessary. INITIAL: _______
Please list the medicine(s) taken by the student, the time/dosage schedule, and the reason for taking them:
Please Circle Preferences: (Or Provide the Medicine(s) Which You Prefer)

♦ Tylenol/Advil for minor pain/fever
♦ Robitussin for cough
♦ Dimetapp/Sudafed for congestion/cold
♦ Benadryl for insect bites or other minor allergic reactions such as hay fever, etc.
♦ Caladryl/Cortisone/Benadryl/Polysporin for itching due to possible poison oak or local
♦ Tums/Pepto Bismol for minor stomach ache I/We, the undersigned, understand that at Disciples Church, Folsom, California, strenuous physical activity, both aquatic and outdoor, are a regular part of any camp session/excursion/trip. Specifically, Winter Camp 2012 will include, but not be limited to, the following activities: outdoor snow play & transportation to and from Jenness Park Christian Camp. To the best of our knowledge, our child, is in excellent physical and mental health, and needs no restrictions from strenuous physical activity. If we have any questions regarding our child’s health, we understand that it is our obligation to seek professional medical advice and to inform Disciples Church of any health problems and restrictions on our child’s activities in writing. We hereby authorize Disciples Church, Folsom, California, as agents for the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable or necessary by, and is to be rendered under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act of the State of California, or to consent to an x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the Dental Practice Act of the State of California. It is understood and agreed that this authorization is given in advance of any specific diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable or necessary. I give my full consent for my child to attend any event sponsored by Disciples Church. I also agree not to hold Disciples Church, staff, nor advisors responsible nor liable in any way for accidents or injuries that my child may incur while on an outing away from Disciples Church or at an event on the grounds of the church. I also acknowledge that it is my responsibility to encourage and communicate to my child the need for his/her safe behavior and conduct on all such activities. PARENT/GUARDIAN NAME/PLEASE PRINT
SIGNATURE & DATE

Please include the name, address, telephone and relationship of two (2) persons that could be
notified in the event that you cannot be reached:

Name:

Source: http://www.discipleschurch.net/wp-content/uploads/2011/10/Fusion2012MedicalRelease.pdf