Frankfort Camp Ministries

MEDICAL RELEASE AND CONSENT FORM  for   Frankfort Camp Ministries

P.O. Box 47039   Indianapolis, IN   46247-0039  765-357-4414   765-459-5814

E-mail frankfortcampministries@hotmail.com    Web Site  frankfortcampministries.com

Camper's Name: _____________________________________________________

Address: ___________________________________________________________

City/state/zip: _______________________________________________________

Birth date:  _______________ Sex: ____________

Home Phone:  (           ) _______________________

Medical Record: 

Immunization Record:  Tetanus/Diphtheria DPT/TD: _______________ (date)

Other:__________________________________________________________________________________

Health History (allergies, asthma, bee sting reactions, present medical condition and other health issues):

Medications:

Drug: ________________ Purpose: __________________ Dosage: _________________

Drug: ________________ Purpose: __________________ Dosage: _________________

Drug: ________________ Purpose: __________________ Dosage: _________________

If an emergency situation occurs, we will make every effort to contact the parents or guardian.

Parent/guardian consent to Medical, Dental, or Hospital Care. 

Limited purpose power of attorney:  Consent to treat a minor

I, ____________________________________ (parent or legal guardian) am the parent or legal guardian of _________________________ (minor's name) hereinafter "my child" who was born on ___________, ______.  I consent to any x-ray, examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child.  This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I further agree to pay all charges for the dental, medical, or hospital care or treatment.

I give permission/power to a staff or adult volunteer (at least 18 years old) of Frankfort Camp Ministries on behalf of all emergency treatment, medical care or dental treatment of ____________________________ (child's name) that is determined necessary or desirable by the child's attending physician or dentist. 

I give permission to the staff, employees, volunteers or counselors at Frankfort Camp Ministries to treat minor injuries and give medicine.

Signature of parent or legal guardian ______________________________________ (parent or legal guardian)

Insurance information:

Health Carrier: _________________________________

Policy Number:  ________________________________

(Please attach a copy of your insurance card when possible)

Parent's/guardian's name:________________________________________________

Address: __________________________ City/state/zip: _______________________

Phone: (       ) ___________________________________________________________

In case of an emergency call: ______________________________________________

Phone: (          ) __________________________________________________________

PHOTO RELEASE - I hereby give permission to Frankfort Camp Ministries to use photos of my child for Frankfort Camp Ministries’ promotional use. 

(Parent's or legal guardian’s signature) __________________________________

ACTIVITIES RELEASE - I hereby voluntarily permit and release my child to attend Frankfort Camp Ministries and participate in all its activities. I agree that Frankfort Camp Ministries, a nonprofit ministry, its officers, staff, employees and volunteers will not be liable for personal injury, death, damage or loss to my child. 

(Parent’s or legal guardian’s signature) ________________________________________

Date:_________________

To copy the above form: right click on a blank area of this page then left click on  select all, right click on the blue area then left click on copy. Now the above document is ready to be pasted into the text document of your choice. Print, fill out and bring with you to Frankfort Camp Ministries for your camp registration.

We look forward to seeing you at camp.