Summer Blast Medical Release Form - Lindell Study Center

2020 Summer Blast Medical Release Form
A separate Registration Form and Medical Release Form must be completed for each camper. Information for up to 2 campers per family may be provided on one Medical Release Form.

* Indicates required field

Name of Child/Camper *

First

Last

Date of Birth *

Medications *

Allergies *

Medical Conditions That May Affect Emergency Treatment *

Name of Child/Camper 2 (if applicable) *

First

Last

Date of Birth *

Medications *

Allergies *

Medical Conditions That May Affect Emergency Treatment *

PARENT/GUARDIAN STATEMENT *

In connection with "Summer Blast 2020" taking place on June 9-11: In the event of injury, I authorize emergency treatment of my daughter(s) 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 *

ONLINE REGISTRATION AND PAYMENT NOT ACTIVE

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