Summer Camp Student Medical Information

This form is to be completed and signed by the student's legal guardian(s). The information we ask you to provide is necessary in the event that your child needs medical treatment while the conference is in session. This must be completed by June 30. It will be returned to you if it is incomplete.

Student Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Student Phone Number*

Parent Phone Number*

Parent Email*

Camp Student Is Attending

Medical Emergency Contact Information

Primary Contact Name*

First Last

Relation to Student*

Cell Phone Number*

Home Phone Number*

Secondary Contact Name*

First Last

Relation to Student*

Cell Phone Number*

Home Phone Number*

Insurance Policy Information

Is the above student covered by health insurance?*

Yes
No

Policy Holder's (P.H.) Name*

First Last

P.H. Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

P.H. Date of Birth*

P.H. Relation to Student*

P.H. Occupation*

P.H. Employer*

P.H. Employer Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Co. Name*

Insurance Co. Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policy #*

Plan #*

Medical Treatment Consent

I, the above- named person, authorize Milligan College and its staff to seek medical treatment for my student as they see necessary at a local healthcare facility. I consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care subsequently deemed necessary by a licensed health care provider during the conference. I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care, and that it is given to provide the Milligan staff to seek medical treatment, and to provide a licensed health care provider with the authority to administer this treatment as he/she judges necessary to the above -named participant. I accept responsibility for payment of all services rendered; I authorize any medical facility that renders services to release medical information necessary for the processing of insurance of insurance claims; and I authorize the payment of insurance claims directly to the medical facility. I understand that whenever possible, the Milligan staff will make a good faith effort to reach the student's listed emergency contacts before seeking treatment. If this is not possible, I understand that the Milligan staff will notify me or my designee as soon as possible of any and all diagnoses and treatments.

Legal Guardian's Electronic Signature*

Date*

Medical History

Below is a series of medical problems a student might have. If they apply to your student, please click the yes button. If you click yes on any of these, please elaborate in the textbox at the bottom.

Food Allergies*

Yes
No

Please notify camps@milligan.edu of any special dietary needs.

Any other health problems or physical limitations?*

Yes
No

If you answered yes to ANY of the above questions, please explain:*

Permission and Release Agreements

Transportation Release

My son/daughter (named above) has my permission to travel with the Milligan Summer Camp on camp-related activities. I understand that he/she will be traveling in a private car, a Milligan College vehicle, or a rented van. I release Milligan College, its staff, and adult volunteers from my liability in case of an accident. I give my permission for trip leaders to take my student to a doctor or hospital and authorize medical treatment, including but not limited to emergency surgery, and will assume the responsibility for medical bills, if any. I understand that I will be contacted if at all possible and that our family physician will be contacted if possible. But, in the event that he/she cannot be reached, Milligan College may choose a reputable physician.

Photo Release

I give my permission for my student's photo to be used (no names will be attached) on the Milligan College websites and/or in other printed materials.

Release and Hold Harmless Agreement

We ask the person attending the conference and his/her parents/legal guardians to accept responsibility and assume all risk connected with attending the Milligan Summer Camp. We release Milligan College from any and all claims, liability, and/or causes of action which we might have growing out of, arising from, or connected to the attendance of the Milligan Summer Camp; we agree to hold harmless Milligan College from any liability which might arise from our attendance of the camp/conference, whether said liability is to us or to some third person who might have a claim, right, or cause of action arising from, growing out of, or related to our attendance of the Milligan Summer Camp.

Please note: Your completion of the information below indicates your permission and release for your student's participation.

Parent/Legal Guardian's Electronic Signature*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Date*