Kilgore College Camp/Extracurricular Activity
Authorization for Medical Treatment & Emergency Contact
CAMP/ACTIVITY NAME AND DATE: ALL UB ACTIVITIES 2020-2021
CAMPER'S NAME:
CAMPER'S DATE OF BIRTH:
Insurance Company (Medical):
Policy No. Policy Holder's Name:
YOU MUST ATTACH A CURRENT COPY OF THE CAMPER'S MEDICAL INSURANCE CARD
Camper's Physician: Physician's Phone No.:
EMERGENCY CONTACTS (No one under the age of 18 is permitted to be listed):
Parent or Legal Guardian's Name:
Address:
Telephone Cell Phone
Additional Contact Name:
Address:
Telephone Cell Phone
CURRENT MEDICATIONS, LIMITATIONS, SPECIAL NEEDS, MEDICAL CONDITIONS OR ALLERGIES OF CAMPER:
Any other information that might help us to provide this camper with the best possible experience in our camp:
AUTHORIZATION:
IF CAMPER IS UNDER 18 YEARS OLD: In the event that I cannot be reached to make arrangements for emergency
medical attention, I authorize Kilgore College (KC) to take my child to a nearby medical facility for necessary treatment
or to administer necessary drugs or treatment. I further consent and authorize any and all necessary treatment for my
child and I accept all financial responsibility for such treatment and understand that KC will not be responsible for any
such medical costs.
In case of sickness or accident, I hereby authorize and consent to have medical personnel selected by KC to order
and/or perform any medical attention or procedure deemed necessary. I understand and agree that KC and its
employees will not, under any circumstances, be held responsible or liable in the event of accident or death arising out
of or related to same medical attention and by signing below, I hereby release and agree to hold KC harmless for any
claims or damages whatsoever related to any medical treatment or care provided to my child/me.
Parent or Legal Guardian's Signature (if Camper is under age 18) Date
Participant's Signature (if 18 or older) Date
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