Clone of Teen Sib Health and Consent Form 2025

Health Information
Physician
Physician Phone Number
Insurance Provider
Policy/Group Number
In case of emergency... Notify*
Emergency Contact Phone Number*
Emergency Contact Relation to Child*
Allergies and Dietary Restricitions
Medication Schedule
Medications prescribed by a doctor are to be given by an adult camp counselor during SibCamp and must be in their original containers, with current dates, specific administration directions, and the doctor’s name. Other medications such as inhalers, creams, ointments, and other solutions should also be properly labeled so medications are given correctly. All medication containers will be placed in Ziplock type bags on arrival and the same will be returned to parents. Please lists all medications (prescription or over the counter) with name, dosage, when to take and other necessary instructions. You may choose to send only enough pills required for the duration of the event and a couple extra incase they are dropped.

A Medication Log will be provided at arrival for parent/guardian approval of medication distribution.
Include medication name(s) and dosage instructions:
Date of Most Recent Tetanus Booster*

MonthDayYear
Date
AsthmaDiabetesCurrent BreaksCurrent SprainsFood AllergyHeart condition
Explain briefly any conditions that are checked.
Any other medical conditions which may affect your participation in physical activity?

Liability and Waiver Signatures
I, {nameOf}, understand that first aid will be available for this event, that my child, {name8}, will be closely supervised, and that if a serious illness or injury develops, medical/or hospital care will be given. However, the staff is not responsible in case of accidental injury or illness. I further understand that in care of serious injury or illness, we will be notified, but if it is impossible to contact us, we give permission for emergency treatment or surgery as recommended by the attending physician.

I also agree not to hold SOAR Fox Cities, Inc. responsible for any personal injury or accident while attending the event(s) selected. SOAR Fox Cities, Inc., its employees and volunteers are not liable for any and all claims, demands, losses, damages, actions, rights of action of whatever kind or nature arising out of, in consequence of, or account of any injuries or incidents which may occur due to participation in SOAR activities.
Signature of parent or guardian*
Date*

MonthDayYear
Date
Photo & Video Permission
I {nameOf}, hereby consent to SOAR Fox Cities, Inc. to use the following of my child, {name8}, for the purpose of community education and awareness. I understand that this material may be used in various publications, recruitment materials, SOAR's website and social media.
PhotographingSocial MediaVideotapingNews coverageSound Recording
Signature of legally authorized guardian/parent/volunteer
Date

MonthDayYear
Date
Should be Empty:

Teen Sib Health and Consent Form