Medical Consent & Release Form

Medical Consent & Release Form

This form must be completed and signed for each individual attending or participating in camp events or programs.
Group Name*
(Example: Borse County Home School, First Baptist Church)
Camper / Participant's Name*

First NameLast Name
Camper / Participant's Date of Birth*
Gender*
Date of Last Tetanus Shot

MonthDayYear
Date
Camper / Participant's Social Security #
(Needed in the event of a hospital or medical office visit)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent / Guardian Email*
example@example.com
Parent / Guardian Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Number*

Area CodePhone Number
Medical Insurance Company
Insurance Policy #
List Any Medications Taken Regularly
List Any Allergies
Other Information
Authorization and Medical Release

I, the undersigned parent or guardian, hereby consent to my child participating in the activities sponsored by The Wilderness Christian Camp. If there are medical conditions which may be relevant to a physician in the event of an emergency, I have listed them on this form. In the event that an emergency occurs, I hereby authorize an adult in charge of said group, to make emergency medical decisions for my child, including consent for surgery, injection, anesthesia, or dentistry if required. If there are any activities that I do not want my child to be involved in, I have listed them in the restrictions section of this form. My insurance coverage shall be primary and The Wilderness Christian Camp’s insurance shall be secondary.

I understand and hereby agree to assume all of the risks which may be encountered, including activities preliminary and subsequent thereto. I do hereby agree to hold The Wilderness Christian Camp and its staff harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property including injury resulting in death.

By sending my child, I do understand that photos and or videos of my child may be recorded and possibly used for future promotion of The Wilderness Christian Camp as deemed important by its staff or agents. I hereby give royalty free consent to photograph and or video my child for the purpose of promotion and documentation.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and the terms of this release are contractual. This is a legally binding agreement that I have read and understand.
Parent/Guardian Signature of Acknowledgment and Consent*

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