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Experience Boundless Presence with us this (or any) week. Be our guest.
Summer Music + Arts Camp Medical Information
Primary Insured Name
Name as it appears on your insurance card.
Health Insurance Carrier
Insurance Carrier Phone
Family Doctor's Name
Family Doctor's Phone Number
Child's current medications
All medicine(s) need to be properly labeled in original pharmacy container. Over the counter medication must also have the youth’s name written on the container.
Please indicate if your child has allergies to:
Please describe allergies in further detail:
Indicate if your child suffers from, or has ever experienced, or is being treated currently for any of the following:
Frequent Upset Stomach
Physical activity restrictions:
Add another child
MEDICAL RELEASE AND WAIVER OF LIABILITY
I hereby release the Church of Saint Barnabas on the Desert, its directors, officers, employees and volunteers from responsibility and liability for any injury or illness that my child may sustain during Summer Music + Arts Camp, including extended full-day camp, if applicable. In the event of an emergency, I hereby authorize an adult leader of this activity, as agents for me, to consent to any x-ray examination, medical, dental or surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate), licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. As a parent/legal guardian I expect to be contacted as soon as possible.
I understand that the church can make a photocopy of this form that is valid for receiving medical attention.
I give permission for my son/daughter to attend Summer Music + Arts Camp 2016 at Saint Barnabas Episcopal Church.
I certify that by typing my name above in the Electronic Signature Field and submitting this form, I intend to sign this document and be bound to the same extent as if I had provided a physical signature.