Camp Medical / Authorization Form

Gymnast / Camper Information

Name

First Last

Birth Date

Which week of Camp(s) are you attending?

Contact Information

This form is being completed by

Name*

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.

Provide 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 Information

In Case of Emergency, Please Contact:

Name

First Last

Primary Phone #

Relationship

Secondary Emergency Contact Information

Name

First Last

Primary Phone #

Relationship

Doctor Information

Doctor's Name

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 taking

Consent to administer the following medication:

Acetaminophen

Ibuprofen

Benadryl

Neosporin

Medical Information

If 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 dosage

Does your child have any allergies? If yes, which ones?*

Release & Policies

Digital Signature*

Date Signed*

Comments

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First Choice

Second Choice

Third Choice

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First Choice

Second Choice

Third Choice

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Camp Medical Release / Authorization Form

Gymnast / Camper Information

Contact Information

Primary Emergency Contact Information

Secondary Emergency Contact Information

Doctor Information

Medical Information

Release & Policies

LOCATIONS

CONTACT

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