To Whom it may concern:

I, the undersigned parent/guardian of ________________________________________ hereby authorize any necessary medical treatment for this minor (under age 18) while participating in any activity conducted under the sponsorship of The Green Swamp Youth Campers or other organizations, groups or companies that provide services, equipment, training or guidance for The Green Swamp Youth Campers. I guarantee payment of all charges incurred as a result of this medical treatment. 

The Youth Campers, or any sponsor, chaperone, officer or persons over 18 are not to be held liable for the costs or charges of any medical treatment.  Should someone representing the interests of the child use this form to obtain medical treatment, I understand that they are signing on my behalf and I alone am responsible and guaranteeing payment of the charges which are incurred.

Information:

Allergies to food, medication, etc.  (if none, so state) ________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Special medical conditions.  (if none, so state)________________________________________________________________________

Family physician  _____________________________________________________________________________

Office address_________________________________   Phone number__________________

                        __________________________________

Insurance Company___________________________________________

POLICY NO. or GROUP NO. ____________________________________

Parent/Guardian Name (please print clearly) ___________________________________________________________

Parent/Guardian Home address  ____________________________________________________________________

_____________________________________________________________________________

Home Phone ______________________________  Cell Phone _________________________

Work Phone _______________________________  Alternative number__________________

Parent/Guardian Signature _________________________________________________________________________

State of Florida, County of _________________

I hereby certify that the forgoing was executed before me this:

___________ day of _______________ 20_______, by ___________________________________ who is :

_______personally known or ________ who has produced ________________________________ as identification.

_______________________________

Notary Public, State of Florida