EcoCamp 2007 Medical Release
Medical history and release form.
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Please print this page, complete the information below, and mail it to us as soon as possible
after completing your child's camp reservation. Please use one form per child. Mail to:

Georgia Nature Center
3001 Salem Road
Watkinsville, GA 30677

Parent/Legal Guardian: _____________________________________

Child's Name: _____________________________________       Child's Birthdate: _____/_____/19____       Sex: MALE FEMALE

Address: _____________________________________       City: __________________       State: ______       Zip: ___________

Telephone Number(s): ____________________________________________________________________________________
                                         (Please list all numbers we should try to reach you at in the event of an emergency.)

Alternate Emergency Contact Person: _____________________________________

Telephone Number(s): _____________________________________________________________________________________

Physician/Pediatrician: _________________________________ Phone: ___________________ Date of Last Physical: ________

Insurance Company: ______________________________________________ Policy/Group No.: _________________________

Dietary Restrictions: _______________________________________________________________________________________

Activities to be Limited: _____________________________________________________________________________________

Current Medications (if any): _________________________________________________________________________________

Medical History (Please put an "X" next to any conditions your child has had.)

_____ Diabetes       _____ Epilepsy       _____ Frequent Ear Infections       _____ Mononucleosis

Allergies: _____ Asthma       _____ Hay Fever       _____ Insect Stings       _____ Poison Ivy

               _____ Penicillin       _____ Other Medication(s), please list: _______________________________________________

List Past Surgeries or Serious Illnesses (include dates): _________________________________________________________


Other Medical Information: ________________________________________________________________________________

The medical history furnished above is to the best of my knowledge true and correct. The child named above has my permission
to engage in all designated activities except as may be noted above. In the event of an emergency, I hereby give permission for
medical personnel selected by camp staff to order X-rays, routine tests, and treatment for my child, and in the event I cannot be
reached, I hereby give permission to the doctor(s) selected by camp staff to hospitalize, secure proper treatment for, and to order
injections and/or surgery for my child named above.

Signature of parent/guardian: X_________________________________________________ Date: ___________________

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