STONEY CREEK RANCH HEALTH, CONSENT

1
STONEY CREEK RANCHHEALTH, CONSENT RELEASE FORM
Group Name___________ Camp Dates____________ Leade
r________________ ? Camper ? Leader

• NOTE TO PARENT/GUARDIAN/GUEST Stoney Creek
  Ranch wants the camp experience to be a safe and
  healthy one. However, in the event of an
  accident or illness, it is important that we have
  the following information
• Medical history
• Medical insurance information
• Name__________________________________ DOB
  __________ Sex ____ Age ____ SSN _____-___-____
• Last First Middle
  Initial
• Parent or Guardian (or spouse) ___________________
  ______________ Cell Phone ( ) _____________
• Home Address _____________________________________
  __________ Home Phone ( ) ___________
• Street Address City
  State Zip
• Business Address _________________________________
  ___________ Phone ( ) _________________
• Street Address City
  State Zip
• Second Parent or Guardian Emergency Contact
  _______________________________________________
• Home Address _____________________________________
  ____________ Phone ( ) _______________
• Street Address City
  State Zip
• Business Address__________________________________
  ______________ Phone ( ) ______________
• Street Address City
  State Zip
• If not available in an emergency, notify Name
  ________________________________________________
• Home Address _____________________________________
  ______________ Phone ( ) _____________

ACCIDENT COVERAGE I understand that my personal
insurance will be the primary coverage for camper
accidents. If you have any questions, please
contact Barrett Rouse at [phone]. My
insurance company ________________________________
Policy Number__________________________ Insurance
Company Address _________________________________
_________________________________ ? Not Currently
Insured
The camper or staff is under the care of a
physician for the following condition(s)
______________________________ ___________________
__________________________________________________
__________________________ Current treatment
(include current medications) ____________________
_____________________________________ ____________
__________________________________________________
_________________________________ Explain any
reported loss of consciousness, convulsion or
concussion _______________________________________
_________________________________________________
______________________________________________ Ope
rations or serious injuries (Dates)
__________________________________________________
_______________ Chronic or recurring illness or
medical condition ________________________________
________________________ Dietary restrictions
__________________________________________________
_____________________________ Current medications
(send with instructions) _________________________
__________________________________ Other disease
__________________________________________________
_________________________________ Name of family
physician ________________________________________
__________________________________ Name of
dentist/orthodontist _____________________________
__________________________________________ Special
health and behavioral considerations
__________________________________________________
________
2
AUTHORIZATION FOR TREATMENT This health history
is correct as far as I know, and the person
herein described has permission to engage in all
camp activities except as noted. I hereby give
permission to the medical personnel selected by
the camp director to order x-rays, routine tests,
treatment to maintain and/or release any medical
records necessary for insurance purposes as
outlined under the HIPPA regulations and to
provide or arrange necessary related
transportation for me or my child. In an
emergency, I hereby give permission and authorize
the physician selected by Stoney Creek Ranch to
secure or administer emergency medical treatment,
including hospitalization and any other emergency
medical procedures which may be needed for the
person named above. I authorize the physician or
dentist to call in any necessary consultants in
his/her discretion. It is understood that this
consent is given in advance of any specific
diagnosis or treatment being required, but it is
given to encourage those persons who have
temporary custody of the minor, and said
physician or dentist to exercise their best
judgment as to the requirements of such. I agree
to remain fully liable and responsible for the
payment of any such hospital, doctor, ambulance,
dental, or medical fees. I further agree that in
giving this permission and authorization, Stoney
Creek Ranch does not assume any responsibility or
liability for the payment of such hospital,
doctor, ambulance, dental, or other medical fees
which may be incurred. Signature of parent or
guardian or adult camper/staffer
__________________________________________________
Persons authorized to pick up child other than
parent or guardian _______________________________
___________