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HEALTH FORM |
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| Purvis Grange Foundation, Inc.
dba Tara Wildlife 6791 Eagle Lake Shore Road Vicksburg, MS 39183 |
Please Print, complete and return or fax to:
Tara Wildlife
6791
Eagle Lake Shore Road
Vicksburg,
MS 39183
(601) 279-4261
fax: (601) 279-4227
This health form constitutes a permission statement which must he signed and completed by parent or guardian. The completed form must be returned to Tara Wildlife. The information in this form is CONFIDENTIAL. The form must be at camp by the child’s first day.
| Camper’s name | _____________________________________________________ | ||
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Last
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first
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middle
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Birth Date ___/___/___ Camper's Social Security # _______-____-_______
| Home Address | __________________________________________________________ | ||
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number and street
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city & state
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zip
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Camper resides with: Both
Parents_____ Father____ Mother____ Other_______________
Father’s Full
Name___________________ Res. Phone_____________Bus.
phone____________
Mother’s Full
Name__________________ Res. Phone_____________Bus.
phone____________
Guardian’s Full
Name_________________ Res. Phone_____________Bus.
phone____________
Alternate responsible person (not parent) to be reached in case of emergency if parent or guardian is unavailable:
| Name: | ______________________ Res. Phone _________ Bus. phone__________ | ||
| Address: | ____________________________________________________________ | ||
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number and street
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city & state
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zip
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Insurance: If you have hospital or health insurance for your
child, please list:
Name of insurance company and policy holder:_________________________________
Policy number______________
AUTHORIZATION
If a medical emergency involving my child/ward arises, I understand that every effort will be made by the staff of Purvis Grange Foundation, Inc. dba Tara Wildlife to contact me as soon as possible. In the event that I cannot be located or in order to avoid delay in medical treatment for my child/ward which might jeopardize the life or recovery of my child/ward, I hereby authorize Purvis Grange Foundation, Inc. dba Tara Wildlife staff members to make medical treatment decisions for my child/ward on my behalf and to authorize qualified health care professionals to provide appropriate medical treatment for my child/ward except for the following medical treatments and/or procedures:_________________________________________________________________
Name________________________________ Date__________
Signature_____________________________ Relationship____________