MEDICAL INFORMATION & AUTHORIZATION FORM

Please complete & return this form with registratation. Medical forms are required for camp participation.

CAMPER'S NAME

BIRTHDATE

Date

PARENT/GUARDIAN NAME (print)

ADDRESS

PH

SECOND EMERGENCY CONTACT NAME

ADDRESS

PH

The camper is under the care of a physician for the following conditions

Recommendations & restrictions while attending camp?

Any medications to be administered (specific dosages)

Any medically prescribed meal plan or dietary restrictions

Any allergies (food, drugs, insects, etc.)

Additional health information

AUTHORIZATION FOR EMERGENCY AND/OR TREATMENT

The authorization granted will be used when absolutely necessary and after every attempt has been made to contact the parent. In case of emergency, I hereby authorize the doctor to which my child is brought (and whomever they designate as their assistants) to perform any emergency procedure or operation, to give treatment and to administer anesthetic to my while participating in Appalachian Kayak Camp Activities.

Signed

Relationship to camper

Insurance Number

Parent 1 Cell

Parent 2 Cell