Microsoft word - confirmation letter.doc

Kaleidoscope Camp
How did you hear about
Information and Health Form
Kaleidoscope Camp?
General Information
Name_____________________________________________ Address___________________________________________ Home Phone_______________________________________ Work Phone_______________________________________ Parent’s Name(s)___________________________________ Home Church ______________________________________ Grade entering in Fall _______________________________ Week Attending:
School____________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Emergency Contact Information
In an emergency call____________________________________Relationship: ____________________ home phone number___________________________work number____________________________ If not available call______________________________________Relationship: ___________________ home phone number___________________________work number____________________________ Health and Medical Information
Physician’s Name_________________________________Phone_______________________________ Ins. Company Policy No. Phone_______________ Group No.__________________________ Policy Holder’s Name:_____________________________ Circle all past illnesses or conditions and give dates where possible. Asthma Bed wetting Bronchitis Colds, frequent__________ Menstruating Yes No Menstrual problems Nightmares, frequent Nose bleeds____________ Sleepwalking Sinusitis Surgery Upset Stomach__________ Other health concerns or details from above__________________________________________________________________ Describe any recent exposure to contagious disease____________________________________________________________ Behavioral considerations to be aware of__________________________________________________________________ Date of last tetanus or DTP_______________________________________________________________________________ Allergies (incl. food, drugs, bee stings, etc.) _________________________________________________________________ Current Medications (list)_________________________________________________________________________________ Describe any medical treatment the camper is currently under____________________________________________________ Medication Information
WCRC Staff will keep and administer all medication. Please be sure all medications are in their original containers with the original label. Please write instructions (dosage and times) for the medications your child is taking (prescription and non-prescription)
and note what non-prescription medications are acceptable to administer if requested by the camper for headaches,
colds, etc.):
_________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Please initial the following that may be given to your child if needed: ___ All of the above
___ Please call first
Consent and Indemnity
(Both parents must sign, unless only one legal parent/guardian)
In signing this document, I hereby certify that the information above is correct. I give permission for the use of video and/or photographs including my son or daughter to be used in camp publicity. I give permission for my son or daughter to be transported in privately owned vehicles for off property activities. I give permission for the release of medical records in case of emergency or illness. I desire that my child participate in the full camp program and all activities unless I advise you I know that Williamsburg Christian Retreat Center (WCRC) is interested in the spiritual, moral, social and physical health of my child. In the event camp personnel deem my child’s behavior unacceptable, or my child demands to go home, WCRC will make every effort to discuss the matter with the parent and reserves the right to send the child home at my expense In the event I cannot be reached, I hereby give permission to the physician selected by the WCRC staff to obtain proper medical diagnosis, hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. I understand that some weeks of camp there is no certified nurse hired by WCRC to administer medication to my child. I understand that the Assistant Program Director or Head Counselor will administer medication according to my written instructions and that WCRC staff will provide First Aid care as needed. I am happy to have my child participate in the Kaleidoscope Camp program. We recognize that some camp activities have an inherent risk of injury. In consideration of permission granted my son or daughter to participate in camping activities, we hereby covenant with WCRC that we will never, individually or as legal guardians of said individuals, institute any action at law or in equity for any personal injuries, or injuries to property, real or personal, caused by, or arising out of, camping and other related activities sponsored by WCRC, its successors and legal representatives. We further agree to indemnify and hold WCRC harmless against any and all cost, damages and expenses, which may be incurred by them as a result of any lawsuit we Signature Date_______________________________ Signature Date_______________________________

Source: http://www.wcrc.info/pdfs/Camp/CurrentMedForm.pdf