Diagnoses. Allergies (food, medication, bees) Chronic or recurrent illnesses or disorders: Does your child take medication for these illnesses listed above? If so, please state the name of the drug and the dosage. Will the medication need to be given during program hours? Yes No If yes, when will it need to be given? Describe how. What should we (you) do if your child has a problem related to his/her medical condition during program hours? What are the signs of problems that may occur? Please list an emergency phone number: Doctor’s Name: Phone # What hospital do you prefer? Insurance Company Policy Holder’s I.D. Medical Consent: In the event that my child, , (Birthdate) , may require medical and/or surgical care while I am out of the city or unable to be reached, I hereby give my consent to medical and/or surgical treatment to Hospital and Doctor or his/her designee to provide this care. I agree to pay all the costs and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent. Signature of Parent/ Guardian Date THE ARC OF Xx XXXXXX COUNTY SUMMER DAY CAMP PROGRAM RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT
Appears in 4 contracts
Samples: Summer Day Camp Enrollment Agreement, Summer Day Camp Enrollment Agreement, Summer Day Camp Enrollment Agreement
