PARENTAL CONSENT FORM FOR MEDICAL TREATMENT
While at Luther College for a college-sponsored camp, health and safety of campers is our main concern. In the event of serious
illness or accident, every effort will be made to contact a parent or guardian. However, if the delay of medical or surgical treatment
would be detrimental to the health of the student, authorization for consultation and treatment by area physicians is requested.
This form must be completed and signed. Please RETURN ASAP….or bring along and turn in at Registration. Mail to: Jim Buzza, Luther College, Decorah, IA 52101, or fax to 563-387-1076. Any questions -- call Jim at 563-387-1389 or email:
WHICH CAMP? JR HIGH SR HIGH BOTH CAMPS______
CAMPER'S NAME BIRTHDATE SEX
HOME ADDRESS CITY STATE ZIP
PARENT/GUARDIAN HOME TELEPHONE
ADDRESS BUSINESS TELEPHONE
PERSON TO BE NOTIFIED IN AN EMERGENCY IF PARENT/GUARDIAN IS UNAVAILABLE:
(name) (relationship to camper) (home telephone) (business telephone)
¨ FAMILY DOCTOR:______OFFICE PHONE#______
NAME OF PRIVATE HEALTH INSURANCE COMPANY
INSURANCE COMPANY ADDRESS
POLICY HOLDER'S NAME POLICY # SOCIAL SECURITY #
¨ DATE OF LAST TETANUS BOOSTER (MUST BE IN LAST 10 YEARS):
¨ PLEASE LIST ANY MEDICAL CONDITIONS YOUR CHILD HAS HAD -- PAST AND PRESENT (may continue on back):
¨ PLEASE LIST ANY FURTHER INFORMATION THAT MIGHT BE BENEFICIAL FOR THE STAFF TO KNOW, INCLUDING EMOTIONAL/BEHAVIORAL AND/OR MENTAL HEALTH CONCERNS:
¨ PLEASE LIST ANY ALLERGIES (MEDICATION, FOOD OR ENVIRONMENTAL) YOUR CHILD MAY HAVE: ______
¨ PLEASE LIST ALL MEDICATIONS and INSTRUCTIONS THAT YOUR CHILD WILL BRING TO CAMP:
¨ IF YOUR CHILD HAS A HISTORY OF ASTHMA, PLEASE BRING INHALER AND/OR MEDICATION !!
¨ IS YOUR CHILD RESPONSIBLE FOR TAKING HIS/HER OWN MEDICATION DURING CAMP? YES____ NO____ IF NO, DOES YOUR CHILD
NEED REMINDERS OR ASSISTANCE: REMINDERS: YES____ NO____ ASSISTANCE: YES ____ NO____
¨ MAY CAMP PERSONNEL ADMINISTER THE FOLLOWING MEDICATION TO YOUR CHILD?
Tylenol: YES____ NO____ Advil/Ibuprofen: YES____ NO____
Sudafed: (brought from home) YES____ NO____ Benadryl Cream: YES____ NO____
Benzocaine Throat Lozenges: YES____ NO____
ALL MEDICAL EXPENSES INCURRED ARE THE RESPONSIBILITY OF THE PARENT/GUARDIAN.
Permission is granted for evaluation and first aid care to be provided by the Dorian Camp registered nurse. Permission is also hereby granted to any duly licensed dentist, physician and/or surgeon to perform emergency dental, medical or surgical service to the above named camper while attending DORIAN MUSIC CAMPS.
DATE
Signature (of parent/guardian if camper is under 18)
ADDITIONAL COMMENTS (may continue on back) ______