Medical Release Medical history and release form. Return to Home Page

Please print this page, complete the information below, and mail it to us as soon as possible
after completing your child's camp reservation. Please use one form per child. Mail to:

EcoCamp
Georgia Nature Center
3001 Salem Road
Watkinsville, GA 30677

Parent/Legal Guardian: _____________________________________ Child's Name: _____________________________________       Child's Birthdate: _____/_____/19____       Sex: MALE FEMALE Address: _____________________________________       City: __________________       State: ______       Zip: ___________ Telephone Number(s): ____________________________________________________________________________________                                          (Please list all numbers we should try to reach you at in the event of an emergency.) Alternate Emergency Contact Person: _____________________________________ Telephone Number(s): _____________________________________________________________________________________ Physician/Pediatrician: _________________________________ Phone: ___________________ Date of Last Physical: ________ Insurance Company: ______________________________________________ Policy/Group No.: _________________________ Dietary Restrictions: _______________________________________________________________________________________ Activities to be Limited: _____________________________________________________________________________________ Current Medications (if any): _________________________________________________________________________________ Medical History (Please put an "X" next to any conditions your child has had.) _____ Diabetes       _____ Epilepsy       _____ Frequent Ear Infections       _____ Mononucleosis Allergies: _____ Asthma       _____ Hay Fever       _____ Insect Stings       _____ Poison Ivy                _____ Penicillin       _____ Other Medication(s), please list: _______________________________________________ List Past Surgeries or Serious Illnesses (include dates): _________________________________________________________ ____________________________________________________________________________________________________ Other Medical Information: ________________________________________________________________________________ The medical history furnished above is to the best of my knowledge true and correct. The child named above has my permission to engage in all designated activities except as may be noted above. In the event of an emergency, I hereby give permission for medical personnel selected by camp staff to order X-rays, routine tests, and treatment for my child, and in the event I cannot be reached, I hereby give permission to the doctor(s) selected by camp staff to hospitalize, secure proper treatment for, and to order injections and/or surgery for my child named above. Signature of parent/guardian: X_________________________________________________ Date: ___________________

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