Tri-Valley Summer Music Camp
EMERGENCY MEDICAL INFORMATION
| Name of Child
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| Name of Parent/Guardian
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| Phone (home):
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Phone (work):
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| Cell:
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| Name of Physician:
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| Phone of Physician:
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| Name of Dentist:
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| Phone of Dentist:
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| Medical Insurance Company:
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| Group / Coverage No.:
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| Allergic to the Following Medications: | |
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| Taking the Following Medications: | |
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| Special Instructions / Precautions: | |
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| I hereby give my consent to the 2009 Tri-Valley Summer Music Camp, to whose care my child has been entrusted, the authorization for any emergency medical treatment, including any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care needed to be rendered on the advice of any physician, surgeon, medical practitioner, or under the provisions of the Dental Practice Act.
The 2009 Tri-Valley Summer Music Camp does not provide medical insurance. Each family must provide their own coverage. |
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| Signature of Parent / Guardian:
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| Date:
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