Fan the Flame Medical Release Form

Fall Fan the Flame 2010

MEDICAL RELEASE FORM

All fields on this form are required. Please fill out the form completely
Print the form - Sign the form and mail it with the registration form.

Camper Information Section
Camper's Full Name:	Birthdate Grade
Parent / Guardian Information Section
Parents Name:
Street Address:
P.O. Box:
City:		State:	Zip:
Home Ph:
Work Ph:		Cell:
Emergency:
Insurance / Medical Information
Cardholder Name:
Insurance Co.:		Group #
Health Conditions More on Back	(List any known Health problems and/or allergies)Write on back if needed
Medications (List any medications your child takes):	My child may take: Aspirin Tylenol Motrin
Dr. Name:	Phone	City

I, the undersigned parent/guardian of the child(ren) named above, do hereby give permission to the director and/or staff to decide when my child is to receive emergency medical attention/or treatment as deemed necessary while at Fall Fan the Flame, Nov. 5-7,2010. I understand that every effort will be made to contact me .
Parents Signature:______________________________________ Date:___________