Medical Insurance Company__________________________ Insurance Policy #___________________
(This above information is needed in case your child or the sponsor has to taken to the hospital and the
parent/guardian cannot be reached.)__________________________________ Date________________
Signature of Parent /Guardian/Sponsor
AUTHORIZATION FOR EMERGENCY CARE TO A MINOR
I/we the undersigned, parent(s) or legal guardian of the minor (name)_____________________________
(birthday)________________, do hereby authorize any X-ray examination, anesthetic, dental, medical, or surgical diagnosis or treatment by any physician or dentist licensed by the State of Oklahoma and hospital service that may be rendered to said minor under the general, specific or special consent of: ______________________________________
(Name of adult sponsor who is temporary custodian of minor)
It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise his/their best judgment as to the requirements of such diagnosis or medical or dental or surgical treatment.
I hereby authorize the hospital to release the following information contained in its hospital records to the representative of the Tulsa Metro Baptist Association concerning Diagnosis, prognosis for
_____________________________________________________ Date of birth ____________________
Name of Camper/Sponsor
This information will be used for insurance billing. ________________________________ Date _______ Signature of Parent or Guardian/Sponsor
PARENTAL AUTHORIZATION TO
This medication form must accompany ALL medication to be given at KMAK. All medications MUST be given to the CampFirst Aid person at the time of arrival in the original container, whether it is a prescription or over the counter medication.
I hereby give my permission to the CampFirst Aid person and to designated camp staff to administer medication to my child at KMAK.
Name of Child ________________________________________________________________Age: ___________ Weight: _____________
I understand that the camp first aid person and/or the KMAK staff shall not be liable to the student, parent, or
guardian of the child for civil damages for any personal injuries to the student, which result from acts or omissions