Medical Waiver
For anyone coming to a Manderley Signature Event
Contact Information
Camper/Guest Name
*
First Name
Last Name
Camper/Guest Email
*
example@example.com
Camper/Guest Phone
*
Please enter a valid phone number.
Camper/Guest Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Visit Information
Group Name
*
Please Select
Day Camp
Name of your church or school
Event Name
*
Please Select
Breakaway
Man Camp
Junior Camp
Day Camp
Seasons Ladies Retreat
Teen Camp 1
Teen Camp 2
Teen Camp 3
Arrival Date
*
-
Month
-
Day
Year
Date
Departure Date
*
-
Month
-
Day
Year
Date
T-Shirt Size
*
Please Select
Child Small
Child Medium
Child Large
Adult Small
Adult Medium
Adult Large
Adult X Large
Adult XX Large
Adult XXX Large
Gender
*
Male
Female
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Any Food Allergies?
*
Yes
No
List Food Allergies
*
Doctor Note
*
Browse Files
Drag and drop files here
Choose a file
Upload a doctor's note listing food allergens
Cancel
of
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Next
Emergency Contact
EC Name
*
First Name
Last Name
EC Phone
*
Please enter a valid phone number.
Is Guest aged 17 or younger
*
Please Select
Yes
No
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Minor Information
Please complete in full and to the best of your knowledge
Camper Birthdate
*
-
Month
-
Day
Year
Date
Camper Grade
*
Please Select
17
16
15
14
13
12
11
10
9
8
7
6
5
Grade just completed
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone
*
Please enter a valid phone number.
Parent/Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Insurance Information
Type of Insurance
*
Please Select
Family Health
Medical Insurance
Self Pay
Insurance Carrier/Family Medical Name
*
Name of Insured
*
First Name
Last Name
Relationship to Camper
*
Insurance/Group Number
*
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Medical Information
Immunizations Up to Date
*
Yes
No
Currently Taking Medication
*
Yes
No
Medications
Dosage
Chronic or Recurring Illness or Medical Condition
*
If none, type "None"
Any Activitiy Restrictions?
*
Please Select
Yes
No
Health or Medical Concerns
*
Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Upload both sides of Insurance Card
Cancel
of
Back
Next
Guest Signature
*
Legal Name
*
First Name
Last Name
Parent/Guardian Signature 1
*
Parent/Guardian Name 1
*
First Name
Last Name
Parent/Guardian Signature 2
*
Parent/Guardian Name 2
*
First Name
Last Name
Submit
Should be Empty: