Summer Blast Medical Release Form

2019 Summer Blast Medical Release Form
A separate Registration Form and Medical Release Form must be completed for each camper.

* Indicates required field

Name of Child *

First

Last

Date of Birth *

Medications *

Allergies *

Medical Conditions That May Affect Emergency Treatment *

Health Insurance Company *

Policy Number *

PARENT/GUARDIAN STATEMENT *

In connection with "Summer Blast 2019" taking place on June 11-13: In the event of injury, I authorize emergency treatment of my daughter by appropriate hospital, physicians, and other health care providers. I hereby release Lindell Study Center and its volunteers and staff from any and all liability in the event of injury. A copy of this release may be used in place of the original, if necessary. Checking this box constitutes my electronic signature for the Parent/Guardian Statement above.

Comment *

CLICK HERE to Pay Fee and Complete Application

PLEASE HAVE PAYMENT INFO READY TO AVOID BEING LOGGED OUT WITH AN INCOMPLETE APPLICATION. THANK YOU.

2019 Summer Blast Medical Release FormA separate Registration Form and Medical Release Form must be completed for each camper.

2019 Summer Blast Medical Release Form
A separate Registration Form and Medical Release Form must be completed for each camper.