Medical and Release Form Medical Authorization and Release FormPlease fill in thoroughly and comment if necessary.Camper's NameInsurance CompanyGroup/Policy NumbersProvider Phone NumberDate of last tetanus vaccinationWill your child be required to take any medication? If so, please list them here:Does your child require supervision with medication? Yes NoIs there any reason your child should not swim?Allergies Hay Fever Poison Ivy Penicillin Other drugs (list in comments) Insect stings (list in comments) Foods (list in comments)History Seizures Diabetes Asthma Fainting Bedwetting Emotional/Behavioral Other (list in comments)Comments:Emergency Authorization and ReleaseBy signing below, I, the parent or legal guardian of the participant listed on this form (hereby referred to as “my camper”), certify that he/she has my full approval to participate in this event. I also certify that the above information is accurate and up to date. Further, by signingbelow, I give my permission to the camp personnel to administer over the counter medication as needed to my camper. I also give permission to the medical personnelselected by the camp director to order X-rays, routine tests and treatment for my camper. Further, in the event I cannot be reached in an emergency, I hereby give permissionto the physician to hospitalize, secure proper treatment for, and to order injection and/or surgery for my camper. I understand I will assume any financial responsibilityfor any expense incurred for said emergency treatment. Further, I do release and hereby agree to hold harmless the camp, its director and staff and any other agents from any and every claim arising, or which may be asserted by me or by any member of my family by reason of participating in any activities associated with Camp Ne-O-Tez. Further, I release the lessor/owner of properties on which the camp is located. (This form may be copied for use outside of camp.)Media ReleaseFurther, for valuable consideration received, by signing below I hereby irrevocably grant to Camp Ne-O-Tez, Inc. the worldwide, royalty-free, right to use the participant’s name, voice, likeness, and image in all forms and media, and in all manners for any lawful purposes, commercial or noncommercial.Matters of public health and safety will be be directed by Ne-O-Tez policy and the judgment of the Director of the week.SignatureRequiredClearUse your trackpad to sign or choose Type It.Your electronic signature is legally binding in Missouri.http://www.moga.mo.gov/statutes/C400-499/4320000230.HTMDateIf you are human, leave this field blank.
