"FAITH OF OUR FATHERS" BUS TOUR/CAMPS

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* Camper's Information

Last Name

First Name

Address

Address 2

City/Town

ZIP/Postal Code

Parish

Email Address

Phone Number

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* Which camp would the camper be attending?

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* Camper's Date of Birth

Date of Birth

Date

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* Age

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* Camper's Grade (2017-18 school year)

7th

8th

9th

10th

Other

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* Any special medical needs? (i.e. medications, allergies, etc.)

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* Any special dietary needs?

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* T-Shirt Size (Adult Sizes)

Small

Medium

Large

X-Large

XX-Large

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* Parent/Guardian Information

Last Name

First Name

Address

Address 2

City/Town

ZIP/Postal Code

Phone Number

Email Address

Cell Phone

EMERGENCY MEDICAL AUTHORIZATION (Part 1 OR Part II MUST BE COMPLETED)

The purpose of this form is to enable parents and/or guardians to authorize the provision of emergency treatment for the above named camper who becomes ill or injured during camp when parents and/or guardians cannot be reached.

Part 1 - To Grant Consent

In the event reasonable attempts to contact me at the above listed phone numbers have been unsuccessful, I hereby give my consent for:

1. The administration of any treatment deemed necessary by:

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* Name of Preferred Physician

Name

Company

Phone Number

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* Name of Preferred Dentist

Name

Company

Phone Number

or in the event the designated preferred practitioner is unavailable, by another licensed physician or dentist.

2. Transfer camper to:

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* Preferred hospital or any hospital reasonably accessible

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* This authorization DOES NOT cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

List camper's medical history (include allergies, medications being taken, any physical impairments, etc.) to which a physician and camp personnel should be alerted to:

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* Signature of Parent and/or Guardian (Typed name authorizes the Diocese of Saint Cloud to provide any emergency medical treatment necessary.)

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* Date

Date

Part II - Refusal of Consent

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* I DO NOT give my consent for emergency medical treatment of my child and I wish the authorities to take no action. In the event of illness or injury requiring emergency treatment, I wish the authorities to . . . (Please explain what action you want camp personnel to take):

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* Signature of Parent and/or Guardian (Typed name states the Diocese of Saint Cloud will take no emergency action.)

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* Date

Date