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Microsoft word - 2010 camper registration form

PO Box 427 - Cedar Hill, Texas 75106-0427
972-291-7156 - 972-291-4958 (Fax) -
Name: _________________________________________________________________ Date of Camp: _____________________Sex: (M/F) _______ Birth Date: _________________________________ Age: _______ Grade Completed by End of School Year 2010 ____________________________ Mailing Address: ___________________________________________________________________________________________________________ Name of Church You Are Attending Camp With: _______________________________________________City/ State___________________________ Parent / Legal Guardian: _________________________________________________________ Relationship: ________________________________ Phone Number: Daytime _______________________________ Evening _____________________________ Other ____________________________ Parent / Legal Guardian Email: ________________________________________________________________________________________________ Additional Emergency Contact Information Other Than Parent/ Legal Guardian: Name: _________________________________________________ Phone__________________________Relationship ________________________ Name: _________________________________________________ Phone _________________________ Relationship ________________________ PARENT/ LEGAL GUARDIAN’S STATEMENT OF PARTICIPATION, ASSUMPTION OF RISK, AND RELEASE OF LIABILITY
I certif y that I a m a ware of the inherent risks associated w ith outdoor camp a ctivities, as w ell as the inhere nt risks of being on camp pro perty. Notwithstanding, I hereby give my child permission to participate in all camp activities. Further, in consideration for Mt. Leb anon agreeing to accept t he above named child as a camper, I hereb y personally assume all risks in connect ion with my child’s attendance and participation in the events at Mt. Lebanon.
In the event t hat my child is injured on camp p roperty or during camp activities, I ackno wledge that I shall be personally liab le for, and agree to pay, all costs and associated expenses incurred in connection with medical and/or dental services rendered to my child in response to said injury.
I understand that my personal insurance coverage will be the primary coverage. Only limited secondary accident and illness coverage is provided by Mt. Lebanon for he alth care needs, such as doctor office visits, hospi tal emergenc y room visits, or ambulance/ medi-flight service s. I acknowledge tha t claims to be sub mitted under such coverage are t ime sensitive, and must be filed within 30 da ys of the date of injur y. I agree to t he release of any records necessary for treatment, referral, billing or insurance purposes.
I agree to release and hold harmless the Dallas Baptist Association, Mt. Lebanon Encampment, it’s trustees, employees, agents, and representatives for any injury, harm, or other damage by any occurrence in connection with my child’s participation in camp activities in any form or fashion. I further agree to release and hold harmless Dallas Baptist Association, Mt. Lebanon Encampment, it’s trustees, employees, age nts, and represe ntatives from any claim by me, or my family, estate, heirs or assigns out of my child’s participation in activities at Mt. Lebanon.
I hereb y autho rize an y medical and/ or sur gical treatment, includ ing but not limited to hospital care, to be rendered to m y chi ld, as needed in t he judgment of the treating ph ysician, who is chosen by the Camp Director or an y employee working under him/her, as circumstances require. I furt her authorize the Mt. Lebanon health staff to render first-aid and to administer medications as pr escribed and programmed on t he Dosage & Frequency
, executed by the parent or guardian.
I agree that I am financially responsible for any damage to camp property caused by my child, including any acts of graffiti.
The above named camper agrees to obey and observe all camp rules, and to fully cooperate with the adult leadership, camp staff, and other campers. I agree that, if in t he judgment of t he adult leaders hip and/ or ca mp staff, m y child becomes a di scipline problem, my child ma y be sent home, at m y expense, and that I will forfeit all camp fees paid.
I agree and consent that my child’s photograph may be used for promotional purposes or publicity material by Mt. Lebanon. I acknow ledge t hat I am the parent or authorize d guardian of th e above named child. By m y signature belo w, I acknowledge tha t I have read and understand the information set forth above, including the release and hold harmless agreement.
____________________________________________________________ ______________________________

1. All prescription and non-prescription medications must be kept in original containers and properly labeled as prescribed by law.
2. All prescription and non-prescription medica tions must be presented to the camp health supe rvisor, or othe r fir st-aid personne l, upon arrival an d
check-in at Mt. Lebanon. Medications must be stored and dispensed from the camp health center.
3. Campers are not allowed to keep or self-administer any medication in accordance with the Texas Department of State Health Services regulations.
4. If a child requires an asthma inhaler or a prescribed antidote for allergies or insect bites, bring at least two to camp. One must be kept closely guarded
by and the responsibility of the camper. The other must be given to and registered with the camp health supervisor or other first-aid personnel.
5. List any medical problems, medical alerts, allergies, or other relevant health information on the Camper Health and Medication Form.
6. Accurately fill out the Dosage and Frequency Chart and write, if necessary, any special instructions or remarks.
7. Place all medications and a copy of the Camper Health and Medication Form and Dosage and Frequency Chart in a heavy-duty, gallon sized zip-lock
bag with the camper’s name and name of church written with a black marker on the outside of the bag. Camp Name: _____________________________________________________________________________ Date:____________________________ Camper’s Name: ___________________________________________________________ Church _________________________________________
INSURANCE INFORMATION (You may attach a photocopy of your current Health Insurance Card.)
Insured Member’s Name: _____________________________________________________ Member ID _____________________________________
Health Insurance Provider: ____________________________________________________ Group ID _______________________________________ Health Insurance Provider Phone Number(s): ____________________________________________________________________________________ Primary Care Physician: ___________________________________________________________ Phone: ___________________________________
GENERAL HEALTH INFORMATION (If necessary, attach additional copies of information which address camper health concerns.)
List any health information that would be relevant to an attending physician in the case of an emergency: _____________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ List any Chronic or Recurring Illnesses or Diseases: _______________________________________________________________________________ _________________________________________________________________________________________________________________________ List any Food, Medicine, or other Significant Allergies: _____________________________________________________________________________ _________________________________________________________________________________________________________________________ Date of last Tetanus Shot: ________________ List Current Immunizations: ___________________________________________________________
I give my permission to the camp’s health supervisor, or other first-aid personnel, to administer the following non-prescription, over-the-counter, medications as indicated by checking below: ____ Acetaminophen (i.e. Tylenol) ____ Ibuprofen (i.e. Advil) _____ Decongestant (i.e. Sudafed) ____ Antihistamine (i.e. Benadryl, Claritin) ____ Antihistamine Cream _____ Antibacterial Ointment ____ Antacid Tablet (i.e. Tums) ____ Cough Medicine _____ _________________________ Parent/ Guardian’s Signature ________________________________________________________ Date __________________________ Medication Dosage and Frequency Chart
Place all medications and a cop y of the Camper’s Health and Medication Form and a copy of the Dosage and Frequency Chart in a h eavy-duty, gallon sized zip-lock bag. Using a permanent black marker, print the camper’s name and name of church on the outside of the zip-lock bag. If necessary, make additional copies of the Dosage and Frequency Chart. Medications must be kept in the original container and properly labeled as prescribed by law. Medication Dosage/Time Monday Tuesday Wednesday Thursday Friday __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________


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B R A N D O N Y O U N G , P H A R M D C A N D I D A T E , U N I V E R S I T Y O F M I N N E S O T AC O N T A C T W I T H A N Y Q U E S T I O N SThe pharmacy is responsible for initiating the prescription claim process by entering patient information as data. Often after claims goes through adjudication a rejection is generated that the pharmacy must address. Some reasons for rejections are

Microsoft word - mg044

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