APPALACHIAN WORK CAMP PROGRAM, INC.
PERMISSION/CONSENT FORM
1. Print this 3 page form
- Complete the entire form … please don’t leave any information blank
- Mail completed form along with copies of the front/back of all medical insurance cards to:
Carol Sherratt
15 Sunset Blvd #1301 OR Scan the completed forms & insurance cards
Beaufort, SC 29907 and e-mail to:
- DO NOT give the completed form to your church leader.
- DEADLINE: May 15, 2013
Camper’s Name ______Date of Birth: ______
Address: ______Home Phone ______
______Cell Phone ______
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EMERGENCY CONTACTS:
Name ______Name ______
Relationship ______Relationship ______
Daytime Phone ______Daytime Phone ______
Evening Phone ______Evening Phone ______
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RELEASE ______camper’s initials (if under 18, parent/guardian must initial)
In consideration of the Appalachian Work Camp Program, Inc.’s agreement to allow the above-named camper to participate in this event, and intending to be legally bound, hereby, I agree to indemnify and hold harmless the Appalachian Work Camp Program, Inc., their officers, directors, chaperones, agents, successors, affiliates, and legal representatives against any loss from any and all claims, demands, and actions at law or in equity that may hereafter at any time be brought by myself, or anyone on my behalf (or my child’s .. if the above-named camper is under the age of 18), for the purpose of enforcing a claim for damages because of any injury or property damages sustained by me (or my child .. if the camper is under the age of 18) as a result of or in any way related to, the above-named camper’s participation in this event.
MEDICAL AUTHORIZATION ______camper’s initials (if under 18, parent/guardian must initial)
In the event of any injury or illness while participating in the work camp, I give my permission for the necessary medical treatment. I agree in case of injury, I will apply my hospitalization and/or accident insurance toward payment of the expenses incurred and will not look to the Appalachian Work Camp Program, Inc. for the payment of any medical costs or injury related costs.
CONSENT TO TREAT ______camper’s initial (if under 18, parent/guardian must initial)
I do hereby authorize treatment of by a licensed medical professional in case of any accident or illness that may so arise, or any hospitalization necessary.
Date of last tetanus shot? (Please don’t leave this blank) ______
Any known allergies? ______
Any physical limitations? ______
Any medically prescribed dietary needs? ______
Any other matters you feel necessary to share? ______
INSURANCE INFORMATION
Subscriber’s Name/Relationship to camper ______
Subscriber’s Employer ______Phone No.______
Subscriber’s Employer’s Address______
This medical/consent form will remain effective until JULY 15, 2013
Signature ______(Parent signature if camper is a minor)
Print name ______Date ______
(Parent’s name if camper is a minor)
Please attach a photocopy (front & back) of camper’s:
1. medical insurance card
2. prescription plan insurance card
3. vision insurance
4. dental insurance
We ask for this information because it’s easier to determine co-pays, insurance carrier phone numbers, etc.
Continue to Page 3
TO BE COMPLETED BY THE PARENT/GUARDIAN OF CAMPERS UNDER AGE 18
PERMISSION ______(parent/guardian initials)
As the parent/guardian of the aforementioned child, I give permission for my child to participate in the The Appalachian Work Camp Program, Inc. from July 4-14, 2013.
MEDICAL MATTERS ______(parent/guardian initials)
I hereby warrant that to the best of my knowledge, my child is in good health, and assume all responsibility for the health of my child.
Of the following statements pertaining to medical matters, INITIAL ONLY THOSE IN ACCORDANCE WITH YOUR WISHES:
______I hereby grant permission for an adult to physically apply sunscreen to my child
______My child is taking medications at present. My child will bring all such
medications necessary and such medications will be well labeled.
Name of medication: ______
______I hereby grant permission for nonprescription medication (such as Ibuprofen,
throat lozenges, cough syrup) to be given to my child, if deemed advisable.
______No medication of any type whether prescription or nonprescription may be
administered to my child unless the situation is life-threatening and emergency
treatment is required.