Microsoft word - uplift 2009 application and medical release form.doc

Session(Circle) (1)6/13-18 (2)6/20-25 (3)6/27-7/2
UPLIFT 2009
Youth Group:
Grade (entering):
T-Shirt Size:
CAMPER’S GENERAL INFORMATION
EMERGENCY CONTACT INFORMATION
Mother’s Info Name:
(or guardian)
Father’s Info Name:
(or guardian) Address:
Youth Min./
Sponsor Info
Emergency
Contact (if above
are unreachable)
INSURANCE INFORMATION
tial:___ DOB:____/____/____Age: ( ) Youth Group:_____________ SS# of Camper: CAMPER’S HEALTH HISTORY
(PLEASE ATTACH ANOTHER SHEET IF YOU NEED MORE SPACE)
Date of last Reaction you
Type of Allergy
Usual treatment for a reaction
reaction
Allergies:
Immunizations
List any medical/psychological/social problems
Date of Diagnosis/Onset
Recent Surgeries
:______________ First Name:_____________Middle Ini Recent (or significant) Hospitalizations or ER visits
~ ~ ~ ~ ~ →Please go to next page → ~ ~ ~ ~ ~
Continued from page 1
List all meds
Name of Medication
The fol owing over-the-counter medications are stocked in the Uplift health station. Please circle any meds you DO NOT wish your child to receive (if any):
Pain Relievers
Gastrointestinal Meds
Allergy/Itch/Cough Meds
Azo (phenazopyridine HCl) – For pain from UTIs Eye drops (naphazoline HCl, pheniramine maleate) Chloraseptic lozenges/spray (benzocaine, menthol) Ear ache drops (chamomil a, mercurius, solubilis sulphur) Mylanta Midol (Tylenol+caffeine+pyrilanine maleate) Topical Wound Ointments
Pamprin (Tylenol+pamabrom+pyrilanine maleate) Feminine Products
Miscellaneous
Please list any other information that may be helpful to the Uplift medical staff.
Medical Release Statement
I ___________________________ (print name) consent to the above-named student to participate in Harding’s Uplift. I further authorize Uplift personnel to sign documents permitting the performance of medical assistance as deemed necessary by legally licensed medical personnel at the time of illness or injury to the above student and will accept the financial responsibility for said medical assistance.
Signature of parent/guardian: Date:
Tuition for Uplift is $190.00. The tuition for the six day session includes a $90.00
deposit/registration fee. The $90.00 deposit is refundable until May 1, 2009. After May 1,
2009, the deposit is non-refundable, but it may be transferable in some cases in the event of
cancellation for any reason. You are not officially registered for Uplift until your deposit is
received and you register online. You must also send this form in. You will be notified within
one week of your acceptance into Uplift. Tuition fees include meals, camp/recreation activities,
and T-shirt. No extra money is needed except for personal items. Campers will not be
permitted to attend Uplift if both pages of this medical release form are not completed in
full.
I __________________________ (camper’s printed name) agree to follow all of the guidelines
of Uplift and Harding University and will cooperate and participate in all of its activities. I
understand that the dress code policy begins when I leave my home for Uplift, and it ends when
I get home.
Signature of Camper: Date:

Source: http://www.upliftonline.com/wp-content/uploads/2009/01/uplift-2009-application-and-medical-release-form.pdf