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Camp Crimson Medical Release Form

by: Calla Hamlin

Camp Crimson Medical Release Form

Marketplace > University of Oklahoma > > Camp Crimson Medical Release Form
Calla Hamlin

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This 1 page Class Notes was uploaded by Calla Hamlin on Friday August 12, 2016. The Class Notes belongs to at University of Oklahoma taught by in Fall 2016. Since its upload, it has received 2 views.


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Date Created: 08/12/16
CAMP CRIMSON Medical Release, History & Physical Limitations Medical Release : In the event of illness or injury occurring to me while involved in camp activities, I consent to X-ray examination, anesthesia, and/or medical or surgical diagnostic procedures or treatment considered necessary in the best judgment of the attending physician and performed by or under the supervision of a member of the medical staff of the hospital furnishing medical services. It is understood that in the event of a serious illness or injury, reasonable effort to reach parents will be attempted. : e t a D : e r u t a n g i S PLEASE PRINT LEGIBLY: Participant’s Name: First Middle Street Address: City, State, and Zip Code: Phone Number: ( ) Date of Birth: Gender: Male Female Social Security Number: MP(dirnle)s In Case of an Emergency: Name of Parents or Guardian: Daytime Phone No: Evening Phone No: Name and Phone # of Family Physician: If Parent or Guardian cannot be reached, please indicate an emergency contact: PNo:name: Relationship to participant: Insurance Information (please provide if known): Medical Insurance Company: Policy Number: Date of Last Tetanus Shot: Blood Type: Are Immunizations current and update: YES NO List all allergies (food and drug) and type of physical reaction (hives, sickness, etc.): List all medications that you are currently using and any surgeries that we need to be aware of: List all physical limitations that you may have:


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