Medical Release Form

Medical Release Form For: Women’s Retreat 2008

2008 Date of Camp Attending: March 14-16

Camper’s Name:_________________________________________

If I become unable to sign or give verbal consent in case of emergency, I hearby authorize the administration of any medical treatment deemed necessary on March 14-16, 2008 by a Mt. Gilead Registered Nurse and/or any physician licensed under the provisions of the Medical Practice Act on the staff of a licensed medical facility.I understand that Mt. Gilead does not carry medical insurance on campers. I understand that medical insurance is the responsibility of the camper.

Insurance carrier:_________________________________________

Policy Number:___________________________________________

Signed (18 yrs or older):_____________________________________Date:___________

Parents Signature (If under 18 yrs):______________________________Date:__________