Blue Mountain Summer Camps 2006
Permission and Emergency Notification Camper's
name_________________________________________Birthdate___________ Permission and
Liability Waiver: My son or daughter, named above, has permission to fully participate
in all Blue Mountain Summer Camp activities during the 2006 summer term. I, as a parent or legal guardian, do hereby grant the Blue
Mountain Summer Camp staff and designated adults the right to authorize
emergency medical treatment for my child named above in the event that I or my
designated representative cannot be reached. I agree to hold harmless Blue
Mountain School and its agents from liability arising out of an accident
situation. The Virginia Good Samaritan Law will apply. Signature:_____________________________Relationship:______________Date:____________ Parent Information: Parent/Guardian:_________________________________________Email___________________ Home Phone:____________________Work
Phone:________________Cell Phone:_____________ Address:_________________________City/Zip_______________State
if not VA._____________ Names of relatives in
the event that parents/guardians cannot be reached:VERY IMPORTANT Name:_____________________Work Phone:______________Cell
Phone:____________________ Name:_____________________Work Phone:_______________Cell
Phone:___________________ Significant Medical
Information: Family
Physician:______________Phone:_____________Dentist:______________Phone:_________ Insurance
Company:_________________Policy#:________________Policy Holder:_______________ Hospital Preference:_____________________ Chronic illnesses
or injuries:_______________________ Allergies (medications, insect stings, food & other) : __________________________________________________________________________________ Date of last tetanus shot or current? _________ Contact
lenses?_________Asthma inhaler?___________ If your child needs Ibuprofen, Tylenol, Homeopathic remedy
or other medications during the day and you would like BMS personnel to provide
any of these medicines, please sign below to authorize him/her to do so. I give
permission to provide to my child: medicine_____________Signature:____________________ Current medications: ( do not include vitamins/ do include
bee sting kits)__________________________ Additional Important Medical
Information:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ |