Camp Medical / Authorization Form

Camp Medical Release / Authorization Form

"*" indicates required fields

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*

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

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

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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