Deadline June 15, 2018.
(Answer the questions below for the primary parent/guardian living in the home)
Cash/Check / Money Order Amount
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Copy of Insurance Card Enclosed or fill in the information:
Prescription Medication and/or Over the Counter Medication Release: If your child is taking prescription or over thecounter medication while attending camp, the Families United staff must have permission to disperse thatmedication. I hereby give the Families United health care staff/counselors permission to administer prescriptionmedications as directed by the prescribing physician and described on the form to my child while attending camp.Every effort is made to keep your child healthy and safe, illness and injuries can sometimes occur. Should a medicalemergency occur, you will be notified immediately. If we are unable to reach you and your child needs medicalattention, your child will be transported to the Washington Memorial County Hospital, Potosi, MO and treated by thephysician on duty.By signing the following authorizations you are giving your consent in advance for medical treatment.
Emergency Treatment Release
I grant permission to have my son/daughter or ward treated, in the event of an illness or injury, at a medical facility.In the event I cannot be reached, I give permission to the physician selected by the Trout Lodge Camp to secure andadminister proper medical treatment, hospitalize, order injection, anesthesia, or surgery for the participant.Furthermore, I hereby state that I am aware and accept the risk inherent in the program activity. The undersigneddoes herby agree to hold harmless and indemnify the Families United, and the Trout Lodge Camp, their officers,agents, and employees, from any and all liability, loss, actions, or those of this participant, in the course of the camp.I agree to reimburse the Families United for any expense that may incur for medical treatment at WashingtonMemorial County Hospital, Potosi, MO. The Washington Memorial Cou
Families United Healthy Relationship program is designed to support and equip individuals with the skills andknowledge necessary to form and sustain a healthy relationship. Participants of the program will NOT be coerced or forced into a relationship or encouraged to remain in an abusive or violent relationship. My signature certifies that I understand participation in the program is totally voluntary. As part of this program, research may be conducted or statistical information may be gathered. Information from this form will be shared with the Program Evaluator only. Participants will never be individually identified in anystatistics or research materials. I grant permission for photographs taken of my youth to be used in advertising and promotional materials.
I grant permission for photographs taken of my youth to be used in advertising and promotional materials.