Middle School Summer Camp Medical Authorization Form

Medical Authorization Form First Baptist Church, Naples Student’s Name:___________________________________________ Circle student’s shirt size: ADULT SIZE: S M L XL XXL YOUTH SIZE: M L Address:_________________________________________________ City/State/Zip:_____________________ Home Phone:____________ Birth Date: ________________________ Current Age: _____ Grade: ________ Circle One: Male Female Mother: ____________ Father:__________Guardian:_____________ Work Phone:_______________ Cell: ___________ Pager: _________ If parent/guardian cannot be reached in an emergency, call: Name: ___________________________Phone: _________________ HEALTH INSURANCE INFORMATION: Carrier___________________Policy No.________________________ Phone___________________________ FAMILY PHYSCIAN:________________ Phone:____________________ Allergies (Drugs, Food, Insects, Etc.):__________________________ CURRENT MEDICATIONS:__________________________________

Immunizations:

Tetanus:_______________ Date of Booster:_______________ Other:__________________ PREVIOUS ILLNESSES: (CHECK AND GIVE DATE TO ALL THAT APPLY) Appendicitis:___________ Heart:___________ Diabetes:__________ Rheumatic Fever:________ Convulsions:_________ Other:_________ I hereby authorize any adult youth worker acting as an agent for First Baptist Church, Naples to be the Limited Guardian for __________________, my minor child, on any church related trips. This Limited Guardianship is for the specific purpose of procuring medical attention for my minor child in emergency situations. This authorizes the above named because of the nature of the emergency, there is not time to contact me or any other natural guardian of the child. I further authorize the above named person to do any of the acts without permission or other order of any court and without specific bonds unless mandatory by law. In consideration of the possible injuries, which could occur in this event, I hereby release all participating groups and persons officially connected with this event from any and all liability for any injury or damages whatsoever arising from any participation in this event.

________________________________________________________ (Signature) (Date) State of Florida, County of Collier Personally appeared before me, the undersigned authority a Notary Public, in and for said state and county, the within-named party, ___________________, who acknowledged the within instrument for the purpose therein contained. Form of ID: Personally known ___________Drivers License________ Other _______ Witness my hand and official seal this ________ day of_____________ 20______. _____________________________(Notary Public)