Keshetbdc.com Boys' Day Camp

Keshet Boys Day Camp Emergency Medical Release Form 2012

Fill out one Emergency Medical Release Form Per Camper

Camper’s Name
Home Phone
Address City/Zip Pediatrician's Name Pediatrician's Phone Medical Insurance Name and Number EMERGENCY INFORMATION
Mother's Name Cell Work Phone

Father's Name Cell Work Phone In an emergency when parent/guardian cannot be reached, please contact the following:
Name Cell Work Phone Home Phone Name Cell Work Phone Home Phone HEALTH HISTORY Past Medical Treatments and Operations (dates) Serious Injuries or Chronic or Recurring Illness Does your child have allergies, please list?
Any medications or medical conditions we should be aware of?
We the parent/guardian authorize Keshet Boys Day Camp to arrange emergency medical care for the above named child while participating in an activity with Keshet Boys Day Camp.
Parent/Guardian Signature Please enter your complete name. This will be accepted as a valid electronic signature
Date