FIRST PRESBYTERIAN CHURCH MEDICAL & LIABILITY RELEASE FORM

FIRST PRESBYTERIAN CHURCH MEDICAL & LIABILITY RELEASE FORM
We must have a copy of this form for each participant in our off-site Summer Day Camp Please complete the following:
Camper's Name
Birthdate

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In case of emergency, please notify

First NameLast Name
Phone #
Format: (000) 000-0000.
Primary Physician
Phone #
Format: (000) 000-0000.
Family Insurance Company
Policy Number
Policy Holder's Name
Group Number
Parent 1 Name
Parent 2 Phone #
Format: (000) 000-0000.
Parent 2 Name
Parent 2 Phone #
Format: (000) 000-0000.
Medical Information
Does the participant have any medical problems? If yes, please explain or check below:

Other
Previous operations or serious illness
Does the participant have any allergies? If so, please describe below:
Food
Penicillin or other meds
Insect stings/bites
Poison sumac/oak/ivy
Other
Does the participant require a special diet? If yes, please explain.
Name of medications and directions for uses (i.e., Tylenol, Motrin, etc.)
Permission for Treatment & Discharge/Liability Release
I, the undersigned, hereby give permission for my child to participate in all activities and events sponsored by First Presbyterian Church during the Summer Day Camp.

I, the undersigned, hereby give permission to the physician selected by the sponsors of First Presbyterian Church to hospitalize and secure proper treatment for the above-named participant in the case of serious illness or injury when legal guardians cannot be reached. I hereby give permission for any such treatment to be rendered, and I agree to bear the total cost of any such treatment.

I, the undersigned, therefore, agree to assume as an explicit condition of my child's participation, any and all risks. I agree to hold harmless the sponsors, First Presbyterian Church, and any other group* from any and all inabilities, claims, demands, and causes of action, whatsoever, which may arise due to the participation of the person listed above during any events of the Summer Day Camp.

I, the undersigned, agree that the information contained within this form is accurate and without error or exemption. I also accept responsibility for any omitted information not requested otherwise. If any changes or additions need to be made, I will contact the Coordinator.

In addition, we are aware of the COVID-19 virus and agree to hold harmless First Presbyterian Church and any other personnel in the event of any injury, illness, or contraction of the virus.

*Any other group, as used in this document, means any and all volunteers, property owners on which camp activities occur, and anyone else who contributes time, supplies, or funding for the camp's operations.
Parent/Guardian E-Signature
Todays Date

MonthDayYear
Date
Should be Empty:

FIRST PRESBYTERIAN CHURCH MEDICAL & LIABILITY RELEASE FORM

Medical Information

Permission for Treatment & Discharge/Liability Release