Haw River United Methodist Church Camp Medical Consent Form

Known Medical Problems and Medications
This information is included to provide information to emergency personnel of medical problems and medications in an emergency situation. In order to keep this person in optimum health it is necessary that medication be given during camp and/or while in transit to or from camp.
Existing Condition
Medication
Dosage Taken
Dosage Frequency
Existing Condition
Medication Taken
Dosage Taken
Dosage Frequency
Existing Condition
Medication Taken
Dosage Taken
Dosage Frequency
Existing Condition
Medication Taken
Dosage Taken
Dosage Frequency
Existing Condition
Medication Taken
Dosage Taken
Dosage Frequency
Existing Condition
Medication Taken
Dosage Taken
Dosage Frequency
Food/Drug Allergies
Is the camper fully vaccinated against COVID-19? (Please note that we are requesting this information in order to ensure that we follow the correct protocols in the event of an exposure)*

YesNo

Medical Consent Authorization:
In the event of an injury, accident, illness or other emergency I authorize my child to be treated by certified emergency personnel such as emergency medical technicians, emergency room physicians and other emergency room personnel such as nurses and laboratory technicians, I agree to accept financial responsibility for the costs related to this medical treatment. As the parent/legal guardian of the camper/minor worker listed here, I hereby give my permission for my child to receive the medication prescribed above during church camp and/or while in transit to or from camp. A practitioner authorized to prescribe medication has prescribed this medication. I am furnishing this medication in the container as issued by the pharmacy. I hereby release Haw River United Methodist Church and its agents and employees from any and all liability that may result from my child taking the prescribed medication.*

Confirmed
Name of Authorized Parent or Guardian*

First NameLast Name
Phone Number*
Date Signed*

MonthDayYear
Signature of Authorized Parent or Guardian
Actual signature will be required at check-in
Should be Empty: