|
www. jdscamps.com |
POTOMAC VALLEY SPORTS CAMP
EMERGENCY FORM/LIABILITY WAIVER
Camper’s Name ________________________
Birth Date__________________
Address_______________________________________________________
Home Telephone_______________
Mother’s Cell_______________
Father’s Cell_____________
Mother’s Name ________________________________
Work/Telephone___________________
Father’s Name _________________________________
Work/Telephone___________________
Emergency Contact: Name
Relationship_______________
Address & Telephone
Numbers_____________________________________________________
Physician’s Name ________________________________
Telephone______________________
Medical Insurance Company ________________________
Policy Information/Number________
Please list current daily and emergency medications.
| MEDICATION | DOSAGE/TIME | PURPOSE |
| ____________________ | __________________ | ______________________ |
1. Has your child had a serious allergic reaction (requiring a physician’s attention) to foods, insect sting or medicine? If yes, explain___________________________________________________________
2. Has your child had Asthma requiring medical attention in the past 2 years? If yes, explain.________________________________________________________________________________
3. Does you child have any health problems that might affect emergency treatment? If yes, explain.________________________________________________________________________________
The Charles E. Smith Jewish Day School and its representative have my permission in an emergency when I or my physician cannot be contacted to administer care and treatment for my child, including care and treatment for injuries and illnesses and administration of medication. The school representative may hospitalize and/or secure proper treatment for my child in case of medical emergency, if in their best professional judgment further delay may jeopardize the welfare of my child. I give permission to release pertinent medical information to the Charles E. Smith Jewish Day School staff and its representatives on a need-to-know basis. I give permission to release information from my child’s medical file in order to facilitate proper medical care. I hereby waive, and release the Charles E. Smith Jewish Day School and JDS Sports Camp, and staff from any and all liability for any injury or illness suffered prior to or while at camp
.| Signature of parent or guardian | Date |
| _________________________ | ______________ |
I hereby give my permission for the Charles E. Smith Jewish Day School to administer non-prescription medication to my child as needed.
I do not give permission for non-prescription medicine to be administered to my child without my consent.
I allow my child to receive only the following non-prescription medicine.