MEDICAL RELEASE FORM

CA NVC FAMILY CAMP


EMERGENCY MEDICAL INFORMATION



We would like to support your health and well being to the best of our ability while you are attending this NVC Family Camp.  In the event of a medical emergency, we would appreciate having the following information, so that we might care for you or your family member(s) with ease, efficiency, and effectiveness.  Please take the time to fill this form out, and bring it to camp with you.  Thank You!  Please print so it’s easily read!

NAMES OF FAMILY MEMBERS

Parent_________________________________________________

Parent_________________________________________________

Child__________________________________________________

Child__________________________________________________

 Child__________________________________________________

Child__________________________________________________

Child__________________________________________________

Child__________________________________________________



EMERGENCY CONTACT PERSON

Name_________________________________________________

Phone Number(s)_____________________________,   __________________________

Email Address__________________________________________

Relationship to you______________________________________

 

 EMERGENCY MEDICAL ASSISTANCE

In case of an emergency requiring immediate medical assistance, I authorize NVC Family Camp staff or volunteers to take medical action on our behalf   YES__________   NO___________, If transfer to a hospital is necessary, I authorize NVC FC staff or volunteers to arrange to have me/us transported to the nearest hospital.   YES_________    NO________

If No, what hospital would you like to be taken to? ______________________________

 

YOUR FAMILY PHYSICIAN’S CONTACT INFORMATION

Name of Physician____________________________________

Name of Clinic_______________________________________

Phone Number of Physician or Clinic____________________________

 

INSURANCE INFORMATION

Name of Insurance Company________________________________________________

Group Policy Number___________________________________

Individual Policy Number________________________________

I have no insurance, and agree to cover any costs relating to my or my family’s medical care while at NCC Family Camp   YES________        NO____________

 

EMERGENCY FIRST AID PREFERENCES

Incase of an emergency

We prefer allopathic remedies (ie: Tylenol, Advil) _______________

We prefer homeopathic remedies  (ie: Rescue Remedy, Arnica) _____________

Other_______________________________________________

 

 ALLERGIES

Please list family members with allergies, and what they are allergic to (bee stings, bug bites, foods, and any medicines)

Family Member Name                                              Allergies

 ______________________________  _________________________________________

 ______________________________  _________________________________________

 _______________________________  _________________________________________

 ______________________________  _________________________________________

 ______________________________  _________________________________________

 ______________________________  _________________________________________

 ______________________________  _________________________________________

 

ADDITIONAL MEDICAL INFORMATION

Is there anything else you would like us to know so that we might better care for you and your family in the event of a minor accident, or a life threatening medical emergency?

 

 

 

 



I agree to hold NVC Family Camp staff, volunteers, Madrone Grove, Sacred Forest Circles, Soul Graffiti and Healing with Compassion, its board, staff, or volunteers, as well as the Dinan-Mitchell family and the Metke-Ancheta family, harmless incase of a medical emergency, or any loss related to a medical emergency while at NVC Family Camp.

Signed_______________________________________   Date___________________

Signed_______________________________________   Date___________________