Registration and Medical Release Form: Counselor

Grace Cathedral Choir Camp August 11th to 19th 2018

Counselor's Name:

The undersigned give permission for and agree to the participation of our above-named son for this choir camp.
We understand that our son may be riding in hired motor coaches, and/or in private automobiles.

I/We agree to pay for any required telephone calls made on our son’s behalf. We give Grace Cathedral permission
to bill us for such calls.

I/We will provide proof of medical insurance applicable to our son’s health coverage. The cathedral must have
authorization numbers, policy numbers and other relevant information to enable hospitalization or treatment,
should it be required. (I have attached a copy of our medical card with this form).

I/We release Grace Cathedral from any responsibility in the event of an accidental injury sustained by our son
while in the charge of the cathedral during choir camp.

I/We understand that reasonable care will be taken to ensure that all participants are safely cared for, but realize
the potential of unintentional injury and accident.

I/We agree that all relevant information with regard to medications, allergies, and other conditions has been
provided on this form.

Signature of Parent or Guardian: ___________________________________ Date: ____________

Emergency telephone number(s) where I/we may be reached 24 hours per day: ___________________________
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Medical insurance carrier: _____________________________________________________________________
Name of insured: __________________________________________ Policy number: ___________________
Family physician: __________________________________________ phone: __________________________
Family dentist: _____________________________________________ phone: __________________________

Medical Information:

Medications taken (list all, including both prescription and over-the-counter): _____________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Allergies (food, medication): ___________________________________________________________________
___________________________________________________________________________________________
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Other medical conditions or pertinent information: __________________________________________________
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Anything else we should know? _________________________________________________________________
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