Medical release

Medical Information & Release
Camp Seven Rivers
Please complete a separate release for each minor that will be participating in Camp Seven Rivers.

Camper’s Personal Information:

Name ____________________________________________________________________________
Address __________________________________________________________________________
City _______________________________ State ______________________ Zip ________________
Home Phone ______________________________ Date Of Birth _____________________________
Insurance Information:

Medical Insurance Company __________________________________________________________
Group Name ________________________________Policy Number __________________________
Comments _________________________________________________________________________
Parent/Legal Guardian Information:

Father’s Name _______________________________________ Home Phone __________________
Address __________________________________________________________________________
Father’s Employer _____________________________ Father’s Business Phone ________________
Father’s Cell Phone _________________________________________________________________
Mother’s Name ___________________________________ Home Phone ______________________
Address __________________________________________________________________________
Mother’s Cel Phone _________________________________________________________________
Mother’s Employer _____________________________ Mother’s Business Phone _______________
Other Person to Notify in Case of Emergency:

Name _____________________________________________ Home Phone ___________________
Address __________________________________________________________________________
Employer _____________________________________ Business Phone ______________________
Relationship to Child ________________________________________________________________
Personal Permission and Medical Information
In the event of an emergency where medical treatment is required, I give my permission to the staff or sponsor to
obtain the services of a licensed physician. Please attempt to notify me immediately concerning any such emergency.
I will check all of the common, over-the-counter medications that my child may take.
Neosporin ointment for wound care
Are there any medications or foods that your child is allergic to? ___________________________________
_______________________________________________________________________________________
Please list medications your child is currently taking:
Name of medication:
_______________________________________________________________________________________ _______________________________________________________________________________________ Please circle any chronic health situation(s): Asthma
Swimming Release
Please choose one of the following statements that BEST describes your child:
_____ My child is a proficient swimmer.
_____ My child is a beginning swimmer who has not yet mastered swimming.
_____ My child cannot swim.
Children will be leaving campus on Tuesday or Thursday to swim at Whispering Pines Pool in Inverness.
Children who remain on campus will participate in water play. Please choose one of the following options for
your child:
_____ My child has permission to travel to and swim at Whispering Pines Pool.
_____ Please have my child remain on campus and participate in water activities on-site.
By signing below, the participant (or parent/guardian if participant is a minor) acknowledges and accepts the risks of
physical injury associated with participation in Camp Seven Rivers. Except for gross negligence on the part of the
sponsor, the participant (or parent/guardian) accepts personal financial responsibility for any bodily or personal injury
sustained during the activity. Further, the participant (or parent/guardian) promises to hold harmless the sponsoring
organization and its representatives for any injury related to the activity.

I have read the above statements and the policies listed below and agree with their statements.
Signed ____________________________________________________ Date ________________
Notary Signature _________________________________ Commission Expires ____________
Failure to have form notarized could result in a delay of treatment or release of your child from an emergency
facility.
HEALTH CARE POLICY
1. All students attending Camp Seven Rivers will have a notarized Medical Information and 2. Camp Seven Rivers will staff a medical advisor on events that require students to be away from home for more than 25 hours. This medical advisor’s certification and license wil be current, and wil be referred to as “nurse” in this document. 3. Parents will be responsible for making the nurse aware of any medical conditions or 4. Medications in the original container with physician’s directions and over-the-counter medications approved by the parent on the Medical Form will be dispensed by Camp Seven Rivers staff. 5. In event of a medical emergency, 911 will be called immediately and every attempt will 6. In the event of an illness, injury, or other medical emergency, the parent/guardian will be contacted immediately. In non-emergency situations, Camp Seven Rivers staff will give care. 7. It is the parent’s responsibility to provide medical insurance for the student. It will be the parent’s responsibility to assume all expenses for any medical treatment. 8. All visits to the nurse will be logged with date, time, reason, and treatment. This log will 9. SRPC will not hold the nurse, or any other adult, liable for any student’s health and/or DISCIPLINE POLICY
1. The Camp Director has the authority and responsibility to create a positive and safe 2. All students attending Camp Seven Rivers will conduct themselves in a civil manner, abiding by all rules and regulations clearly set forth for the event. 3. Parents will assume responsibility for student’s behavior. Any student not conducting themselves in an appropriate way, which endangers themselves or others, will be sent home at the parent’s expense, as deemed necessary by the Camp Director. 4. The Camp Director has all authority to use appropriate discipline measures suitable for 5. Property damages will be repaired/replaced at the parent’s expense.

Source: http://www.sevenrivers.org/pdf/children/Camp_Seven_Medical_Release.pdf