Emergency Authorization Form
Please print this form and bring it to registration on the first day of camp.
Note that if this form is not completed and signed by a parent or guardian the camper my not be permitted to stay at camp.
Camper Name _________________________________ Camp Session ______________________
Parent/ Guardian Name _____________________________________________________________
City ____________________ State ____ Zip Code________ Home Phone (_____)_____-________
Emergency Contact ______________________________________Phone (_____)_____-________
Any Activity/ Diet Restrictions ________________________________________________________
Current Medications ________________________________________________________________
Insurance Co. _____________________________________ Policy # ________________________
Doctor __________________________________________ Phone (_____)_______-___________
- Medications must be in the original bottle. Perscription medication must have the pharmacy label stating person's name and dose ordered by physician. All medications will be turned in during check-in.
- I understand that I must give permission before my child receives any over-the-counter medications.
- My child has permission to participate in all activities on or off the grounds.
- I give permission for Shiloh Bible Camp to use any photo or video of my family in publications. I release my right to any kind of remuneration for said photos or videos.
- In case of a medical of a medical emergency for my child, I authorize Shiloh Bible Camp Staff to act in their best judgement to seek medical attention through appropriate means, including ambulance transport and emergency room treatment. I also accept responsibility for expenses incurred through such treatments.
Parent/ Guardian Signature ________________________________Date _______________