CAMP ENTERPRISE
STUDENT MEDICAL RELEASE
Both sides of this form must be completed and returned
to camp personnel prior to admission to the camp.
NO STUDENT WILL BE ALLOWED TO PARTICIPATE IN
CAMP ENTERPRISE ACTIVITIES UNTIL THIS FORM IS RECEIVED.
Student Name ______Date of Birth______
Home Address______/______/______
(Street) (City) (Zip)
School ______
Parent or Guardian Work Information:
Parent/Guardian Name______Relationship ______Name of Employer ______Work Phone ______
Parent/Guardian Name______Relationship ______Name of Employer ______Work Phone ______
Student's Physician______Office #______
Office Address______Emergency #______
Hospital Preference______Phone #______
Does student have any health or physical conditions that would limit participation in camp activities? ______
If yes, explain______
______
Does student wear contact lenses? ______Yes______No
Does student have any chronic or recurring illness (i.e., seizures, bleeding disorders, asthma, diabetes, etc.? ______If yes, explain______
______
Does student have any known allergies or drug reactions (i.e., animals, food, hay fever, insect stings, medicines, plants, pollen, etc.)? ______If yes, explain ______
______
Has student had tetanus (lockjaw) toxoid shots? _____ If yes, year the original shots were given ______, date of last booster shot______.
My son/daughter/ward, ______, in consultation with the event qualified first aider, has my permission to take or use the medications checked below as needed:
___ acetaminophen___ ibuprofen___ decongestant
___ antihistamine___ Calamine Lotion___ cortisone ointment
___ throat lozenges___ liquid Benadryl___ antibacterial ointment
(Aspirin and aspirin compounds (i.e., Pepto-Bismol) will not be dispensed.)
My son/daughter/ward will be bringing the following medications to camp. (Please include both prescription and non-prescription medications.) Medications must be in the original container and labeled with the student's name, name of drug, dosage and current date.
______
______
My son/daughter/ward has the following special dietary needs______
______
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Authorization to Provide or Obtain Emergency Treatment
I give my permission for my son/daughter/ward to be transported to/from and to attend and participate in all activities of the Camp Enterprise Weekend.
I hereby authorize personnel of the Austin Rotary Club's CampEnterprise to provide, or act on my behalf, in obtaining any medical, dental or surgical treatment for the above-named student if such personnel believe such treatment is necessary for emergency reasons.
In the event that a parent/guardian cannot be reached during an emergency, the following person(s) should be contacted:
Printed Name of Other Emergency Contact RelationshipEmergency Contact #
1)______
2)______
I have read and completed both sides of this form.
Signed______Date______
(parent or legal guardian)
LSGSC/CE/MEDICAL2006/10-2005
RETURN COMPLETED FORM TO CAMP ENTERPRISE CHAIR:
c/o Wendy Nolin, The Ginac Group, 6200 Bridge Point Pkwy, Bldg 4, Ste 200. Austin, TX 78730
fax 512-672-1047, or, scan and e-mail to ,
or, bring to the CE orientation meeting.