SUMMER ROCK CAMP 2017 MEDICAL RELEASE
Complete and return before your child's camp session begins
One form per child is required to participate in SRC
Primary Care Physician's Name
Physician's Phone Number
Medical Insurance Provider
Allergies to medications
Medical conditions for which the camper is receiving treatment
Prescription drugs the camper is taking
Other pertinent medical information
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S) As custodian of the aforementioned minor child/camper, I hereby give permission for my child to participate in all activities (unless otherwise specified) and assume all risks and hazards incidental to the program. I also hold harmless Summer Rock Camp of Palo Alto (SRC), its staff, and appointed assistants.
I hereby grant my authorization and consent for Summer Rock Camp of Palo Alto (SRC) to administer general first aid treatment for minor injuries or illnesses, administer prescribed medications, and, if the injury or illness is severe, to seek professional emergency personnel to attend, transport, and treat my child and to issue consent for any medical care deemed advisable by a licensed medical professional or institution. I authorize SRC to exercise best judgment upon the advice of medical or emergency personnel. This completed form may be photocopied.
I give my authorization and consent
I do not give my authorization and consent
Do Not Fill This Out