Fillable Waiver Form Minor (Gettysburg College)

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Waiver Form Minor (Gettysburg College)

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The Waiver Form Minor (Gettysburg College) form is 2 pages long and contains:

  • 4 signatures
  • 0 check-boxes
  • 68 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Gettysburg College

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Minor Participant Information & Waiver Form
The information collected in this form is confidential and will only be shared in a medical emergency.
It is collected to ensure the safety of your camper. Thank you for taking the time to fill out the form in its entirety.
Camper’s Full Name:
Address:
City: State: Zip Code:
Home Phone Number: Cell Number:
Date of Birth: Gender:
1
st
Emergency
Contact Name:
Relation to Camper: Home Phone Number:
Cell Phone Number: Work Phone Number:
Place of Employment:
2
nd
Emergency
Contact Name:
Relation to Camper: Home Phone Number:
Cell Phone Number: Work Phone Number:
Place of Employment:
Health Insurance Company Name:
Policy or Member ID Number: Group Number:
In whose name is the insurance listed:
Is your child under medical treatment: YES NO
List condition(s):
Please list any medications your child currently takes.
Prescription:
Over the counter:
Can your child self-medicate?
Please check pain reliever that may be given: Tylenol: Ibuprofen: Other:
Does your child have any allergies? YES NO
List allergies & treatment for each:
Does your child have asthma? YES NO
List medications & asthma “triggers”:
Date of most recent tetanus shot:
Camper Information
Emergency Contact Information
Insurance Information
Medical Information
Name of Family Doctor:
Phone number of Family Doctor:
Check any physical conditions and explain treatment:
Vision: Wears Glasses? Contacts? Other:
Eye Doctor Name & Phone Number:
Heart or Lungs:
Epilepsy/Seizure Disorder:
Attention Deficit Disorder/Hyperactivity:
Please list any pre-existing conditions or medical concern(s) that would limit participation at camp.
has brought/will bring the following medications with him/her to camp.
(name of camper)
He/she has my permission to use them. He/she may not share them with any other camper.
Medications:
Parent/Guardian Signature: Date:
I, , am aware that I may NOT share any medications with other campers.
(name of camper)
Camper Signature: Date
In the event that medical treatment for my child is required, I authorize a representative of Gettysburg College to take my child to Gettysburg Hospital,
147 Gettys St., Gettysburg, PA 17325. I also understand that my insurance is primary if medical treatment is rendered.
Parent/Guardian Signature: Date:
(actual signature is required)
:
In consideration for the permission granted by Gettysburg College and
[insert name of
camp/organization] for Camper to participate in this Camp, on my behalf and on behalf of the Camper, and each of my and the Camper’s heirs,
executors, and administrators, I hereby waive and release any and all causes of action, claims, suits, damages, and judgments, in any form what-
soever, arising from or by reason of any and all known or unknown, foreseen or unforeseen bodily or personal injuries (including death) or property
damage, resulting from the Camper’s participation in the Camp and related activities, against Gettysburg College and
[insert name of camp/organization], and their employees, administrators, trustees, volunteers, and agents.
IN WITNESS WHEREOF, and intending to be legally bound, I have executed this document below.
Signature of Parent/Legal Guardian:
Date:
Medication Permission
Medical Treatment Authorization
This form must be completed, printed, and mailed, emailed (scanned as a PDF file),
or faxed to the Camp Directors.
Waiver/Release Information
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Waiver Form Minor (Gettysburg College)

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Completed 22 July 2020

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