Ohio Medical Release Form 1

Mid-Ohio Valley Work Camp: Medical Release Form
Name:___________________________________ Congregation:_____________________________
Home Address: _____________________________________________________________________
Gender:
□ Male
□ Female
Birthdate: ____________________________
Custodial Parent/Guardian: ____________________________________________________________
Address: ____________________________________________________________
Home Phone: ___________________
Work:__________________ Cell: ____________________
Second Emergency Contact: ______________________________
Phone:_____________________
Relationship: ______________________________
Insurance Information:
Is the Participant covered by medical/hospital Insurance?
Group # ___________________________
□ Yes
□ No
Carrier or Plan Name:_____________________
Allergies or Medical Conditions/surgeries: (List all known, including Food, and medical management
if any):
___________________________________
___________________________________
___________________________________
___________________________________
Medications Taken: Please list ALL medications (including nonprescription drugs) taken routinely and
what they are for. Bring enough medication for this event. Keep it in the original packaging/bottle that
identifies the physician/name of medication/dosage and frequency taken. (Administration of medication
is the responsibility of the individual or Chaperone of their group unless arranged in advance.)
___________________________________
___________________________________
___________________________________
___________________________________
By signing, I give my child permission to hold and administer his/her own medications. As a
guardian, I am responsible for my child’s medication administration.
Parent’s Signature: ________________________________________________
I hereby give my approval and consent to this application and therefore relieve any sponsoring
congregation or Work Camp staff member from any and all liability for sickness, accidents, or
injuries of any nature or cause whatsoever, while attending, traveling to or from Work Camp. I
further give authorization for the camp directors or any approved camp personnel to administer such
acts of first aid as seem necessary, and to transport the camper to a doctor or emergency room to
secure the services of a licensed physician. I further promise to utilize family insurance for any
major medical care requiring hospitalization. (You must have family insurance).
____________________________________
__________________________________
Signature of Parent or Guardian (if under 18)
Signature (if over 18)
Date___________________