Camp Medical Release / Authorization Form "*" indicates required fields Gymnast / Camper InformationName First Last Birth Date MM slash DD slash YYYY Which week of Camp(s) are you attending? Contact InformationThis form is being completed byMotherFatherGrandmotherGrandfatherAuntUncleLegal GuardianName* First Last Primary Phone #*Email* Please provide a list of approved people to pick up the gymnast/camper.*Anyone not on this list will not be allowed to take the gymnast/camper with them without previous confirmation provided to Olympiad Gymnastics from their legal guardian OR if the person not on this list provides a 4-Digit PIN to identify themselves as an approved person. Add RemoveProvide a unique 4 DIGIT PIN for security approval*In the circumstance in which an approved person cannot pick up their gymnast/camper this 4 Digit PIN can be provided by the person to the Olympiad Gymnastics Staff that is attempting to pick up the gymnast/camper. Primary Emergency Contact InformationIn Case of Emergency, Please Contact:Name First Last Primary Phone #Relationship Secondary Emergency Contact InformationName First Last Primary Phone #Relationship Doctor InformationDoctor's Name First Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Doctor's Phone #Your Insurance Carrier Group # Policy # Please list all medications the gymnast is currently takingConsent* I understand & permitBy digitally signing this document below, I understand and give permission for Olympiad Gymnastics to arrange for emergency medical/surgical/dental care and treatment (including diagnostic procedures) necessary to preserve the health and well being of my child. I acknowledge that I am responsible for all charges in connection with any care and treatment renderedMedical InformationIf it is necessary for your child to receive medication during the camp day, please do the following: 1. Send the medication to camp with a responsible individual (if you are unable to bring it) and give it to the camp coordinator. 2. Send the medication in the original container, properly labeled with the original pharmacy dosage information.Please tell us what medication you will be providing and when you would like your child to receive their dosageDoes your child have any allergies? If yes, which ones?*Consent* I understand, agree & will complyI give permission to the personnel of Olympiad Gymnastics to dispense the above medication to my child according to my instructions provided. I understand that Olympiad Gymnastics will NOT assume any responsibility for accidents and/or medical and/or dental expenses received as a result of participation in the camp. In the event Olympiad Gymnastics cannot reach any of the emergency contacts provided, I give my permission to give whatever immediate treatment is necessary and/or take my child to the Christiana Hospital or A.I. Dupont Children's Emergency room. Due to the strict licensing requirements for Olympiad Gymnastics, we are obligated by the state of Delaware to have on file current immunization records for all campers attending our camp. You must provide a photocopy of your child's immunization records that indicate they are up to date on the following shots; Diphtheria, Rubella, Measles, Tetanus, & MumpsRelease & PoliciesConsent* I have read and agree to all terms for campI understand that no reduction in the tuition will be made for late arrival or early departure. I hereby release Olympiad Gymnastics and its personnel from any and all claims that occur during camp. Permission is hereby granted for photographs and or videos to be taken of my child at camp. Photos may be used in marketing materials and/or posted online on sites like Facebook, You Tube and our website to be shared with you and others online. Olympiad has the right to use images in the use of marketing, brochures and other advertisements. Permission is also granted for my child to attend all scheduled field trips, swim sessions, and be transported in Olympiad designated vehicles. There are NO refunds or exchanges.Digital Signature* Date Signed* Comments
