Adventure Camp 2014 Medical Release Form

Student Name *
Student Name
Date of Birth *
Date of Birth
Parent Name *
Parent Name
Address *
Address
Parent Phone *
Parent Phone
Doctor's Name
Doctor's Name
Doctor's Phone *
Doctor's Phone
Doctor's Address
Doctor's Address
Medication Required during Adventure Camp? *
Please provide 2 Names with Phone Numbers
Explain restriction and list what can and cannot be done Examples of week's activities: Dancing, Swimming, Running, Walking, Playing Outdoors which may include climbing