Camper Emergency Contact Form

Emergency Contact

Team Jacksonville .

Emergency Medical Information/Permission for Treatment/Liability Release Form

Name of Camp

Name of Minor Participant

DOB Minor Participant

EMERGENCY MEDICAL INFORMATION

I/We represent that the minor participant has no restrictions that would prevent him/her from participating in all activities related to the Camp. However, the Camp should be made aware of certain medical information related to the minor participant, since it may impact his/her safety and health during participation in the Camp and all related activities.

I/We understand that this information will be kept confidential and is to be disclosed only in the event of an emergency.

The important medical information is as follows (list all allergies and any medications that the minor participant is taking):

Attach additional documentation if necessary

Upload File

EMERGENCY CONTACT INFORMATION

First / Last Name

Phone

Relationship

Address

PERMISSION FOR TREATMENT/LIABILITY RELEASE

I/We, the parent(s)/legal guardian(s) of _____________________, hereby give permission and authorize Team Jacksonville and its faculty, staff, and representatives to obtain and give consent for emergency medical and/or surgical treatment reasonably necessary to care for the minor participant during the Camp.

I/We understand that every attempt will be made to contact the emergency contact prior to taking emergency action.

I/We give permission and authorize hospital staff, EMT’s, emergency medical staff, attending physicians, and specialists to act according to their best judgment when rendering medical treatment. I/We fully understand and agree that

I/We will be financially responsible for any medical care needed during the Camp or resulting from an injury sustained at the Camp. In consideration of the minor participant being permitted to participate in the Camp

and related activities, I/We and my/our personal representatives, assigns, executors, heirs and next of kin (“Releasors”) hereby forever RELEASE, WAIVE, DISCHARGE and COVENANT NOT TO SUE Team Jacksonville , its officers, employees, faculty, agents, attorneys, insurers, and officials (“Releasees”) from and against any and all liability, claims, demands, actions, judgments, damages, expenses, fees, fines, penalties, losses, suits, proceedings, and costs thereof (including attorneys’ fees and court costs), in law or in equity, of any kind and nature, that may arise in relation to emergency medical treatment provided to the minor participant.

I/WE UNDERSTAND THAT I/WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM AND THAT I/WE HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME/US.

Parent/ Guardian Printed Name

Parent/Guardian Signature

Select a date

Minor Participant's Health Insurance and Policy Number

Minor Participant's Primary Care Physician

LIONS DEN

Emergency Contact

LIONS DEN