Emergency Contact and Medical Information for Scout Camp Weekends &

Theatre Camp 2007

M

F

Child’s Name

Date of Birth

Sex

Parent’s/Guardian’s Name

Parent’s/Guardian’s Name

( [       ])

(        ])

(        ])

( [       ])

Home Phone

Work Phone

Home Phone

Work Phone

Address

Address

City, ST  ZIP Code

City, ST  ZIP Code

Alternative Emergency Contacts

Primary Emergency Contact

Secondary Emergency Contact

([       ])

([       ])

([       ])

(         )

Home Phone

Work Phone

Home Phone

Work Phone

Address

Address

City, ST  ZIP Code

City, ST  ZIP Code

Medical Information

Hospital/Clinic Preference

Physician’s Name

Phone Number

Insurance Company

Policy Number

Allergies/Special Health Considerations

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the even that neither parent/guardian can be reached in the case of an emergency.

Parent’s/Guardian’s Signature

Date

I give permission for my child to go this field trip. I release First Frontier, Inc. and their staff from liability in case of an accident during activities related to First Frontier, Inc., as long as normal safety procedures have been taken.

Parent’s/Guardian’s Signature

Date

Witness Signature

Date