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HEALTH / RELEASE FORM

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 Camp Alpha Health / Waive and Release Form

This form is to be completed by parents/guardians within

the current year. Anyone with a known complicating

medical problem or who has had an operation, serious

illness or convulsive disorder since his/her last health

examination should secure a written statement from

his/her doctor giving permission to participate in

he particular activity. This form should be brought

with you on the first day of camp.

Child's name______________________________________         

Parent/guardian name ________________________________

Address________________________________________  

City/state/zip_____________________

Phone (_____) __________________

Date of last physical examination_______________    

Date of last tetanus shot______________

Family medical/hospital insurance carrier: _____________________

Health history (check as appropriate):

__asthma      __diabetes      __heart disease      __measles      

__chicken pox     __mumps     __kidney disease      __ear infections  

    __convulsions    __German measles

drug allergies (specify)____________________________________

food allergies (specify) ___________________________________

insect sting allergies (specify)______________________________

plant allergies (specify) ___________________________________

other _________________________________________________

Operations, serious illness, or injury since last physical examination;

or other physical conditions:

Comment where applicable:

bed-wetting      constipation      fainting eye      glasses     hearing aid

menstruation      sleep disturbances

Does your child have any special fears (storms, water, insects, etc.)?

 

Are there any special dietary restrictions that should be observed?

 

Please list any medications your child is taking.

 

 

To the best of my knowledge, the health history listed above

is correct and the above named has my permission to engage

in all program activities at this event except as noted.

I understand that adult supervision will be provided.

If a serious illness or injury develops, medical and/or hospital

care will be given and that staff members for the activity are

not responsible in the event of accidental injury or illness.

I further understand that in the event of a medical emergency

 I will be notified. In the event I cannot be reached,

I hereby give my permission to the attending physician

to hospitalize, secure treatment for, and to order injection,

anesthesia, or surgery for the child as named above.

I hereby waive and release Morris Area Community Education,

the City of Morris, and Morris Area School and their

employees from any and all liability for any damages or 

injuries while participating in any activities. I agree to

allow Morris Area Community Education to use any

photos of me and/or my children for publicity purposes.

Parent/guardian signature__________________________________                  Date_______________

 

 

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