Medical Release Form

Thank you for choosing Sea Camp at Old Dominion University. We work hard to make camp a memorable experience for you and your child. In order for our staff to better serve our campers, please fill out this form. Make sure that your child returns it to us on the first day of Sea Camp. Children may not attend Sea Camp without this form. If you have any questions please call 757-683-4285.

Child’s Name:______________________________________

 

Scheduled Week of Camp:__________________________________________________

 

Age of Child:____________________________

 

Parent/Guardian Name:_____________________________________________________

 

Parent/Guardian Phone Numbers:

Home:___________         Work:___________   Cell:_______________

 

Emergency Contact’s Name:________________________________________________

(an emergency contact is necessary in the event that we cannot reach a parent or guardian)

 

Emergency Contact’s Phone Numbers:

Home:__________   Work:__________   Cell:__________

 

Primary Physician:________________________________________   Phone:_________

 

Insurance Company:______________________   Policy Number:___________________

 

Allergies/Medications:_____________________________________________________

 

***Please note: Staff members of Old Dominion are not authorized to administer medications to your child.***

 

I,__________________, as the parent or guardian of the above named child hereby give my permission for them to participate in the specified activity.  I further agree to emergency medical treatment if necessary.

 

 

 

Signature:___________________________________     Date:_____________________

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