Attention Campers! You must print out this form, fill it out, and attach a copy of your insurance card to it. You MUST bring this completed form to camp!
Garland Farms
Permission to Treat
I hereby authorize Garland Farms, its owners and contractors, who are caring for my child the week of (check all that apply):
DAY CAMP
Week
1: Monday June 11 - Friday June 15
Week
2: Monday June 18 - Friday June 22
OVERNIGHT CAMP
Week 1: Sunday July 8 - Friday July 13, 2007 _________
Week 2: Sunday July 15 to Friday July 20, 2007. _________
Week 1-2 stay over: Saturday July 14,2007._________
to seek medical
treatment as necessary for her well being.
Garland Farms, its owners and contractors, are authorized to sign as
necessary to insure that medical treatment will be given to my child in a
timely manner in my absence. This
child is protected by medical insurance.
Child's name:
Parents' names:
Insurance Company:
Insurance Company Phone Number:
Parents' Phone Number, cell, & email:
Emergency Phone Number:
I give permission for my child to receive medical treatment in my
absence.
____________________________________
Date: ___________________________
Parent's Signature
____________________________________
Date: ___________________________
Witness
*Please attached a copy of your
insurance card.
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