Northern Michigan Mennonite Summer Camps Medical Release Form

Northern Michigan Mennonite Summer Camp 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:		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 Summer Camp, July 13-17,2010. I understand that every effort will be made to contact me .
Parents Signature:______________________________________ Date:___________