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___________________
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___________________