South Park Church Children’s/Student Ministry



Devar Emet Messianic Synagogue & Outreach

Summer 2015

Camp HaDerekh Parental & Medical Release Form

7800 Niles Skokie, IL 60077 / (847) 674-9146 / info@ /

One form may be done for the entire family as long as the following apply:

1. Parent/Guardian(s) and Minors all have the same address

2. All Minors have the same insurance carrier/information

PART I: MEDICAL RELEASE FORM

Parent/Guardian Information:

First and Last Name of Parent/Guardian(s) __________________________________________________

Address______________________________________________________________________________

City/Zip _________________________________________ Home Phone __________________________

Cell Phone #1____________________________________ Cell Phone #2__________________________

Insurance & Medical Information:

Insurance Carrier: ______________________________________________________________________

Group: _________________________________ Member Number: ___________________________

Family Physician: _________________________ Phone: ___________________________________

Address of Physician: ___________________________________________________________________

Other contact in case of emergency:

(This should not be an adult previously listed on this form)

Name: ______________________________________________ Relationship: _____________________

Address: _____________________________________________________________________________

Home Phone: _____________________________ Cell Phone:__________________________________

TO WHOM IT MAY CONCERN:

As the parent or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the following minor(s) in the event of a medical emergency, which in the opinion of the attending physician may endanger the life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after reasonable effort has been made to reach me. I also release Devar Emet Messianic Jewish Outreach, Devar Emet Messianic Synagogue, and other organizations and individuals involved of any liability for accidents incurred during Camp HaDerekh 2015.

This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Signed___________________________________________Date_______________

Questions can be directed to: Rachel Meiri 847-721-0211 or info@

Received Date: _______/_______/______ Received By: ____________________________________

PART II: PARENTAL RELEASE FORM

To whom it may concern --

At Camp Haderekh, youth will have the opportunity to learn about their Jewish Identity and G-d as well as build new relationships while growing old ones; they will also have the opportunity to do a wide range of activities. All necessary safety precautions will be taken, but some activities have higher risks than others. Take a moment to read over our list of activities, then sign the below waiver. Additionally, please note that select pictures & video of activities may be used by Devar Emet Messianic Jewish Outreach & Devar Emet Messianic Synagogue for promotional purposes.

Activities at Camp HaDerekh may include but are not limited to:

Hiking, fishing, archery, BB guns, capture the flag, banana boating, canoeing/kayaking, swimming, gaga ball, basketball, field activities, tie-dye, horseback riding.

As the parent or guardian, I do herewith authorize my youth to participate in all the above listed activities as well as any other activities that the Camp HaDerekh director and staff provide for the campers. I understand that all necessary safety precautions will be taken, and that any injuries that may take place during activities is not the fault of the Camp staff. I also release Devar Emet Messianic Jewish Outreach, Devar Emet Messianic Synagogue, and other organizations and individuals involved of any liability for accidents incurred during any of the 2015 Camp HaDerekh activities.

Name (printed) ________________________

Signed___________________________________________Date_______________

This activity is sponsored by Devar Emet Messianic Synagogue & Outreach,

a Community of Jews who believe and teach thatYeshua (Jesus) is the promised Jewish Messiah.

CHILD #1

First and Last Name of Minor ________________________________________ Male/Female (circle one)

Birth date (M/D/YR) ______________________ Grade in Fall 2015 _____________________________

Minor lives with ( Mom ( Dad ( Both ( other_______________________________________________

Date of last Tetanus shot: ____/_____/_________

Are there any medical concerns we should be aware of? (chronic illness or other condition): ( No ( Yes if yes, please explain: ___________________________________________________________ ___________________________________________________________

Please list any prescription medications your child may be bringing:

_________________________________________________________________________________

Nonprescription Medication form:

In the cause of illness and/or injury, the following non-prescription medications that may be available and can be used on an as needed basis…

If you would prefer a medication not to be administered, please cross out the medications the camper should not be given.

Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin)

Phenylephrine decongestant (Sudafed PE) Pseudoephedrine decongestant (Sudafed)

Antihistamine/allergy medicine Guaifenesin cough syrup (Robitussin)

Diphenhydramine antihistamine/allergy medicine (Benadryl) Sore throat spray

Dextromethorphan cough syrup (Robitussin DM) Generic cough drops

Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Antacid (Tums)

Laxatives for constipation (Ex-Lax) Lice shampoo or cream (Nix or Elimite)

Topical Antibiotic cream (Bacitracin, Neosporin) Hydrocortisone cream

Calamine lotion Aloe

Medication Allergies to be aware of:

______________________________________________________________________________

Other Allergies (i.e. Food allergy, Bee sting or insect bite)

______________________________________________________________________________

By signing this you are allowing the remaining nonprescription medications to be given if needed to your child

X____________________________________________________________________________

CHILD #2

First and Last Name of Minor ________________________________________ Male/Female (circle one)

Birth date (M/D/YR) ______________________ Grade in Fall 2015 _____________________________ Minor lives with ( Mom ( Dad ( Both ( other_______________________________________________

Date of last Tetanus shot: ____/_____/_________

Are there any medical concerns we should be aware of? (chronic illness or other condition): ( No ( Yes if yes, please explain: ___________________________________________________________ ___________________________________________________________

Please list any prescription medications your child may be bringing:

___________________________________________________________________________________

Nonprescription Medication form:

In the cause of illness and/or injury, the following non-prescription medications that may be available and can be used on an as needed basis…

If you would prefer a medication not to be administered, please cross out the medications the camper should not be given.

Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin)

Phenylephrine decongestant (Sudafed PE) Pseudoephedrine decongestant (Sudafed)

Antihistamine/allergy medicine Guaifenesin cough syrup (Robitussin)

Diphenhydramine antihistamine/allergy medicine (Benadryl) Sore throat spray

Dextromethorphan cough syrup (Robitussin DM) Generic cough drops

Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Antacid (Tums)

Laxatives for constipation (Ex-Lax) Lice shampoo or cream (Nix or Elimite)

Topical Antibiotic cream (Bacitracin, Neosporin) Hydrocortisone cream

Calamine lotion Aloe

Medication Allergies to be aware of:

______________________________________________________________________________

Other Allergies (i.e. Food allergy, Bee sting or insect bite)

______________________________________________________________________________

By signing this you are allowing the remaining nonprescription medications to be given if needed to your child

X____________________________________________________________________________

CHILD #3

First and Last Name of Minor ________________________________________ Male/Female (circle one)

Birth date (M/D/YR) ______________________ Grade in Fall 2015 _____________________________

Minor lives with ( Mom ( Dad ( Both ( other_______________________________________________

Date of last Tetanus shot: ____/_____/_________

Are there any medical concerns we should be aware of? (chronic illness or other condition): ( No ( Yes if yes, please explain: ___________________________________________________________ ___________________________________________________________

Please list any prescription medications your child may be bringing:

___________________________________________________________________________________

Nonprescription Medication form:

In the cause of illness and/or injury, the following non-prescription medications that may be available and can be used on an as needed basis…

If you would prefer a medication not to be administered, please cross out the medications the camper should not be given.

Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin)

Phenylephrine decongestant (Sudafed PE) Pseudoephedrine decongestant (Sudafed)

Antihistamine/allergy medicine Guaifenesin cough syrup (Robitussin)

Diphenhydramine antihistamine/allergy medicine (Benadryl) Sore throat spray

Dextromethorphan cough syrup (Robitussin DM) Generic cough drops

Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Antacid (Tums)

Laxatives for constipation (Ex-Lax) Lice shampoo or cream (Nix or Elimite)

Topical Antibiotic cream (Bacitracin, Neosporin) Hydrocortisone cream

Calamine lotion Aloe

Medication Allergies to be aware of:

______________________________________________________________________________

Other Allergies (i.e. Food allergy, Bee sting or insect bite)

______________________________________________________________________________

By signing this you are allowing the remaining nonprescription medications to be given if needed to your child

X____________________________________________________________________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download