Microsoft word - 2013smed.doc

Cowboy’s Rest
PO Box 1081 Elko, NV 89803 ◊ (775) 934-9806 ◊ www.cowboysrest.org 2013 Activity Permission & Medical Release Form
Please complete and sign this form. You may mail it to Cowboy’s Rest or bring it with you when you
drop off your camper. We must receive this form in order for your child to participate and remain at
Cowboy’s Rest.
Camper Agreement (must be signed by camper) I, ___________________________, will obey all directions and rules given by the Cowboy’s Rest staff. If I break any rules, I understand that I could be sent home or not allowed to participate in certain activities during the remainder of camp. Parent Permission (must be signed by parent/guardian) My son/daughter, _________________________________ has my permission to participate in activities at Cowboy’s Rest Christian Camp in Jiggs, Nevada. June17-21 (High School Camp 1)
July 22-26 (Junior High Camp 1)
June 24-28 (Kids’ Camp1)
July 15-19 (High School Camp 2)
July 29-August 2 (Junior High Camp 2)
July 8-12 (Kids' Camp 2)
In the event of a medical emergency, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for the registered camper named on this form. I also agree to pay for any fees incurred, and I understand that Cowboy’s Rest and its staff will not be held responsible or liable for any related expenses. Camper’s Name: _________________________________________ Gender:______ Age: _____ Birth date: ____/____/_____ Mailing Address: _____________________________________ City: ____________________ State: _____ Zip:________ Parent/Guardian Names: _________________________________________________ In case of emergency, please first attempt to contact:
Name: _______________________________ Phone: (_____)___________________ relation to camper: _______________ Other emergency contacts:
Name: _______________________________ Phone: (_____)___________________ relation to camper: _______________ Name: _______________________________ Phone: (_____)___________________ relation to camper: _______________ Name: _______________________________ Phone: (_____)___________________ relation to camper: _______________ The camper’s family insurance plan is the primary source of coverage for accidents.
Insurance Carrier: _______________________________________________ Phone: ________________________________ Holder’s Name: _________________________________________________ Policy Number: __________________________ please see reverse
Family Physician: ________________________________________________________ Phone: ________________________ Date of last Tetanus shot: _____________ Activity restrictions? _________________________________________________ Allergies: _____________________________________________________________________________________________ Food Allergies: ________________________________________________________________________________________ Current Medications: ____________________________________________________________________________________ I give permission to the camp nurse to administer to my child any of the medications listed below, unless I specify otherwise. (Please initial each medication to indicate permission. Write in any allergies or preferences next to the category.) Pain Relievers/Fever Reducers: _________________________________________________________________________
_____ acetaminophen (Tylenol) _____ibuprofen (Advil) _____ sodium naproxen (Aleve) Upper Respiratory/Allergy: ______________________________________________________________________________
____ phenylephrine (Sudafed) ____ diphenhydramine (Benadryl) ____ guaifenesin (expectorant) ____ loratadine (Claritin) Digestive: _____________________________________________________________________________________________
_____ simethicone (Gas-X) _____ bismuth subsalicylate (Pepto Bismol) _____ calcium carbonate (Tums) Topical: _____________________________________________________________________________________________
_____ Benadryl cream _____Neosporin _____ lubricating eyedrops Emergency (parent will be notified): _______________________________________________________________________
Additional Information for Camp Nurse:

Additional Information for Counselor: (Is there anything you feel would be beneficial for your child’s counselor to
know? examples: family, emotional, behavioral, social, or sleep concerns; strengths or weaknesses; likes or dislikes. This
information will only be seen by medical staff and the child’s counselor.)

Source: http://cowboysrest.org/SUMMER/2013sMED.pdf