Camper Medical Form, Emergency Treatment Release, Waiver and Photography Release

Medical, Emergency, Waiver and Photography Release - Ducktails

Step 1 of 2

Camper Medical Form
Camper's Name*
Age*
Child's Physician*
Dr. Phone*
Does the Camper have any allergies, including food, medications, or insect bites? Describe:
Is camper currently taking any medications? List medications and reason for medications:
Will camper be taking medication during camp hours? Please explain below:
A completed medical administration form and a doctor’s note will be required.
Does camper have any pre-existing medical conditions? Describe:
Is camper current on all immunizations as required for school attendance in the state of Illinois?*
- Yes
- No
Are there any other conditions of which we should be aware? Are there any restrictions or limitations on your child's activities?
Is there any other information that you believe we should know to better serve your child?
Emergency Treatment Release
As a parent and/or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor and any and all other medically trained personnel of the child/ward in the event of a medical emergency which, in the opinion of the attending physician may endanger his/her life, cause disfigurement, physical impairment or undue discomfort if delayed. The authority is granted only after a reasonable effort has been made to reach me. This release was completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.
Type Signature*
Date*
Date Format: MM slash DD slash YYYY
*
- I affirm that by typing my name I am verifying that all information is correct.
Statement of Medical Condition
I am not aware of any medical conditions that my child has that would prevent him/her from safely participating in any camper activities.
Type Signature*
Date*
Date Format: MM slash DD slash YYYY
*
- I affirm that by typing my name I am verifying that all information is correct.
Please feel free to contact the Camp Coordinator if you have any concerns that you wish to discuss.

Waiver and Release of All Claims
Camper's Name*
Please read this form carefully and be aware that in registering yourself or your minor child/ward for participation in the camp program, you will be waiving and releasing all claims for injuries you or your child/ward might sustain arising out of the above said program.

I recognize and acknowledge that there are certain risks of physical injury to participants in the camp program and I agree to assume that full risk any such injuries, including death, damages or loss regardless of severity which I or my child/ward may sustain as a result of participating in any activities connected or associated with any such program. I waive and relinquish all claims I or my child/ward may have against Boone County Conservation District and its officers, agents, servants and employees as a result of participation in this program. I do hereby fully release and discharge the Boone County Conservation District and its officers, agents, servants and employees from any and all claims from injuries, including death, damage or loss which I or my child/ward may have or which may accrue to me or my child/ward on account of my participation or the participation of my child/ward in the above program. I further agree to indemnify and \hold harmless and defend the Boone County Conservation district and its officers, agents, servants and employees from any and all claims resulting from injuries, including death, damages and losses sustained by me or my child/ward, and arising out, connected with, or in any way associate with the activities of this program.
Type Signature*
Date*
Date Format: MM slash DD slash YYYY
*
- I affirm that by typing my name I am verifying that all information is correct.
Photography Release
We (I) the undersigned parent/guardian or participant listed below give permission to photograph the participant of a Boone County Conservation District program on the date(s) listed below. We (I) understand that these photographs will be used for promotional purposes for the Boone County Conservation District in print, media, newspaper, and internet venues.

We (I) understand and agree that neither we (I) or my child/ward will receive financial reimbursement for these photographs and that they are the property of the Boone County conservation District into perpetuity.
Type Signature*
Date*
Date Format: MM slash DD slash YYYY
*
- I affirm that by typing my name I am verifying that all information is correct.

Medical, Emergency, Waiver and Photography Release - Ducktails

Step 1 of 2

Camper Medical Form

Emergency Treatment Release

Statement of Medical Condition

Waiver and Release of All Claims

Photography Release

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