Great Falls First Church of the Nazarene
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| Male Female
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| Medication Currently Taking
| The medication cannot be administered unless they are in their original container or are accompanied by a note from the prescribing Physician.
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| Does your child take medications without assistance supervision?
| Yes No
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| Present Medication Conditions, chronic conditions, handicaps?
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| Date of last tetanus shot:
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| Has camper been expose to infections/contagious diseases in the last 3 weeks?
| Yes No
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| Doctor
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| Family Insurance Company
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| Social Security Number
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Medical Release
Medical Release must be received and filled out completely before the camper is eligible
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Emergency Contact Person
Parent/Guardian Name
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| Address--If Different from Camper
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| Home Phone Number
| use tab from country to get to this box or you will be unable to type in the area code.
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| Work Phone number
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Alternate Contact Person
Parent/Guardian Name
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| Address- If Different from Camper
| Only needed if different from Camper
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| Street Address
| Only needed if different from Camper
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| Address Line 2
| Only needed if different from Camper
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| City
| Only needed if different from Camper
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| State / Province / Region
| Only needed if different from Camper
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| Postal / Zip Code
| Only needed if different from Camper
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| Country
| Only needed if different from Camper
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| Phone Number
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Parent Guardian Consent: As parent/guardian, I agree that the information given is correct and I give approval for the above named to participate in the basketball camp at the First Church of the Nazarene and submit to their leadership.
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I, the undersigned, hereby authorize the camp director/nurse as my agent to give consent to medical and or surgical treatment by a licensed physicatin in the state of MT for the above named person when such treatment is deemed necessary by such physician and parent or guardian cannot be reached within a reasonable time.
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The authorization is in effect during the basketball camp dates. I understand all reasonable safety precautions will be taken at all times by the First Church of the Nazarene and its agents.
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I understand the possibility of unforessen hazards and know the inherent possibilities of risk. I agree not to hold the First Church of the Nazarene, its leaders, employees, and volunteer staff liable for damages, losses, diseases or injury to the camper
This section must be signed prior to the start of the camp for the camper to be eligible. We will have a copy of the form available for you to sign.
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| Parent/Guardian______________________________
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Image Verification
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