Insurance Company Phone Number
Policy Holder's First Name
Policy Holder's Last Name
This health history is complete as far as I know. In the event that I cannot be reached in an emergency, I hereby give permission to the physician(s) selected by the camp director to hospitalize, secure treatment for, and to order injection, anesthesia, or surgery for my child named above.
I authorize the release of any records necessary for treatment, referral, billing, or insurance purposes. I hereby give permission for the nursing and medical staff to administer prescription and non-prescription medication brought from home, stocked in the health center, or prescribed while at camp. I understand that any incidental charges, including medical bills for any accident, illness, or medications will be my responsibility. Camp Illahee, its medical providers or pharmacists may not file insurance information (we will provide receipts so that you can file). I understand that all accounts with camp and its medical providers must be settled within a month after the close of my daughter’s session.
It is the responsibility of parents/guardians to become familiar with all of the activities and programs offered by Camp Illahee as described in literature, online videos, and in our parent handbook. I understand that my child’s participation in Camp Illahee and any activity is entirely voluntary, and that it is my responsibility to communicate to the camp directors if there are any restrictions to the normal activity program for my camper.
I further recognize that there are hazards and dangers inherent in camp events and programs, and Camp Illahee cannot guarantee that the participants, equipment, premises and/or activities will be free of hazards, accidents and/or injuries. I have further instructed my child in the importance of knowing and abiding by the camp’s rules, regulations, and procedures for the safety of camp participants.
By typing my full name in the signature box below I acknowledge that I have carefully read and agree to the above terms and conditions, that all of the information I have provided to Camp Illahee is accurate, that I am electronically signing this instrument on my own behalf and as parent or guardian of Participant, and that I am willing to engage in this transaction by electronic means.
Please use your browser print function to print a copy of this for your records before submitting.