TBD
Medical Treatment Authorization Form
Participants Name
D.O.B __________
1. List any medical conditions that camp personnel should be aware of
2. List any medications currently taking _______________________________
3. List any allergies ________________________________________________
In case of an emergency please contact:
Name _____________________________________________
Cell phone _______________________________________
Daytime phone ____________________________________
Medical insurance company ________________________
Insurance policy number __________________________
______________________________________, as parent or legal guardian of the participant named above, authorizes DBSS to seek medical and/or surgical treatment which is reasonably necessary to take care of the participant. I further authorize the medical facility that treats the participant to release all the information needed to complete the insurance claims. I acknowledge my responsibility to pay all costs associated with the participant’s medical care and authorize all insurance payments, if any, to be made directly to the medical facility.
__________________________________________________
Signature (Parent or Guardian)
Date
Medical Treatment Authorization Form
Participants Name
D.O.B __________
1. List any medical conditions that camp personnel should be aware of
2. List any medications currently taking _______________________________
3. List any allergies ________________________________________________
In case of an emergency please contact:
Name _____________________________________________
Cell phone _______________________________________
Daytime phone ____________________________________
Medical insurance company ________________________
Insurance policy number __________________________
______________________________________, as parent or legal guardian of the participant named above, authorizes DBSS to seek medical and/or surgical treatment which is reasonably necessary to take care of the participant. I further authorize the medical facility that treats the participant to release all the information needed to complete the insurance claims. I acknowledge my responsibility to pay all costs associated with the participant’s medical care and authorize all insurance payments, if any, to be made directly to the medical facility.
__________________________________________________
Signature (Parent or Guardian)
Date