HEALTH INFORMATION & TREATMENT CONSENT FORM
Participant Name _______________________________________________________________________________
INSURANCE INFORMATION
Is the participant covered by Medical/Accident/Hospital Insurance? ? Yes ? No
If so, indicate insurance company or insurance carrier name_____________________________________________
Policy holder’s name (primary insured) _____________________ Relationship to participant__________________
Insurance participant ID number___________________ Other ID or group numbers__________________________
MEDICAL PROVIDER CONTACT INFORMATION
Doctor’s Name__________________________________________________________Phone (____)____________
Dentist’s Name__________________________________________________________Phone (____)____________
Are there any other important medical providers specific to this child? ____________________________________
_____________________________________________________________________________________________
RESTRICTIONS
Please list any restrictions on the participant’s activities, dietary restrictions or other restrictions of which the staff should be informed. ____________________________________________________________________________
_____________________________________________________________________________________________
ALLERGIES
Please list all known allergies including those to medications, food, and environment. If non known, please write “none known”.
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Allergy to: |
Normal reaction and management of the reaction: |
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HISTORY OF MEDICAL ILLNESS
Please list any medical illnesses you or your child has or has had.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
MEDICATIONS
Will the participant need to take any medications on a regularly scheduled basis during event? ? Yes ? No
The participant or participants guardian/leader is solely responsible for any and all administration of his or her own prescription or non-prescription medications. Medication must be accompanied by written instructions from the parent or physician in the original containers.
Participant’s Statement
I understand that there is danger and chance of injury in all activities, including those at this event. I understand that the staff will place limits on my participation and inform me of rules with the intent of reducing the risk of injury to me. I agree to abide by all rules and limits on my participation.
Participant’s signature ____________________________________________________ Date__________________
(this must be signed by all participants, including those under 18 years old)
Parents/Guardians Authorization
I understand that there are inherent risks in all activities, included those at this event. I have read the participant’s statement above and acknowledge that I know this minor child has signed this statement. I have explained the above participant’s statement to this child (for younger children) and I will encourage this child to abide by all restrictions and rules, including those intended to reduce the risk of injury or death to this child.
Recognizing the normal hazards inherent to the type of activity in this program/event, “Heartland Christian Camp” in the event of accident or illness or any other emergency, I authorize care or treatment to my child as they deem necessary and appropriate, and I further authorize the adult leaders to make arrangements for, and to authorize on my behalf, emergency medical care for my child by licensed hospitals, physicians or clinics, to whom I will be responsible for payment. I understand that every effort will be made to contact me prior to authorization of treatment with the one exception being cases of emergency, in which 911 will be called first. The information in this document is considered confidential and will only be used in the unlikely event of injury or illness.
This health history is correct and complete as far as I know, and the person named and described herein has permission to engage in all event activities except as noted.
_____________________________________________________________
Signature of Parent or Guardian or Leader Responsible for the child (or
participant if 18 years old and older)
Printed Name__________________________________________________
Date___________________________