Medical Waiver/Insurance Form

Use this as a guide in creating your medical waiver. It is best to include this as part of a brochure that the interested person can tear off, fill in, and turn in to you. Change the red type to fit your event(s).

Insurance Information

Camp Name
Registration


Please complete the registration and medical waiver, detach and send to:
Camp Name
Street address
City, WA Zip code

Name Age
Parent/Guardian Name  
Address  
Home Phone  
In case of emergency please call:  
Name  
Phone  
Please list any health conditions, allergies, or any other thing that we should be aware of:
Primary Insurance Provider
Policy Number
Family Physician
Physician Phone Number
Parent Signature
Printed Name

Medical Waiver


Date goes here

I, the parent of the named child who will be attending the Camp Name, hereby give my approval for a duly appointed member of the faculty of the arena to seek or administer emergency first aid or medical attention required for the safety or well being of said child while participating in any and all of the activities of the camp on the said dates noted above. I do further hereby release, absolve, indemnify, and hold harmless the camp staff, the Shoreline School District, Shorecrest High School, the attending physician, hospital, or medical group involved in the emergency medical attention or first aid of my child.

I hereby give my approval for participation in any and all of the activities of the Camp Name during the dates noted above. I do further release, absolve, indemnify, and hold harmless the camp staff, the Shoreline Schools District, Shorecrest High School, and the supervisors of the Camp Name.

In case of emergency, if the family physician cannot be reached, I authorize
(name of particicant) to be treated by another physician who is available or the nearest medical facility.
Parent Signature Date