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Lindell Study Center
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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
*
If no medications, type "none".
Allergies
*
If no allergies, type "none".
Medical Conditions That May Affect Emergency Treatment
*
If none, type "NA"
Name of Child/Camper 2 (if applicable)
*
First
Last
Date of Birth
*
Medications
*
If no medications, type "none".
Allergies
*
If no allergies, type "none".
Medical Conditions That May Affect Emergency Treatment
*
If none, type "NA".
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.
Checking this box will constitute your electronic signature.
Comment
*
ONLINE REGISTRATION AND PAYMENT NOT ACTIVE
PLEASE HAVE PAYMENT INFO READY TO AVOID BEING LOGGED OUT WITH AN INCOMPLETE APPLICATION. THANK YOU.
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