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Parent Pack

Medical Authorization and Emergency Contact Form

Camper Name
First Last
Medical Condition
Please list any Medical Conditions
Medications
Name of Medication Dosage Time to be Given
Doctor's Information
Doctor's Name Doctor's Number
Medications
Name of Medication Dosage Time to be Given
Doctor's Information
Doctor's Name Doctor's Number
Medications
Name of Medication Dosage Time to be Given
Doctor's Information
Doctor's Name Doctor's Number
I hereby give permission to Brighthouse Day Camp to administer the following medications to my child.
Your Name
Your Name
Your Name
Emergency Contact
Name Relationship to Camper Phone Number
Emergency Contact
Name Relationship to Camper Phone Number
Emergency Contact
Name Relationship to Camper Phone Number
Authorization for Pick up *Excluding Mom and Dad
Name Relationship to Camper Phone Number
Authorization for Pick up *Excluding Mom and Dad
Name Relationship to Camper Phone Number
Authorization for Pick up *Excluding Mom and Dad
Name Relationship to Camper Phone Number
List ALL Known Allergies
Allergy Treatment Reaction
Please list all known allergies for your child and treatment needed.
List ALL Known Allergies
Allergy Treatment Reaction
Please list all known allergies for your child and treatment needed.
List ALL Known Allergies
Allergy Treatment Reaction
Please list all known allergies for your child and treatment needed.
List ALL Known Allergies
Allergy Treatment Reaction
Please list all known allergies for your child and treatment needed.
Permission for my Camper to be included in pictures associated with Brighthouse Day Camp, these photos may be used for advertisement and/or publicity with Brighthouse Day Camp
- Allow
- Do Not Allow
Permission to apply sunscreen to my Camper, I will provide sunscreen in my Camper's backpack.
- Allow
- Do Not Allow
Permission to apply face paint to my Camper during special activities.
- Allow
- Do Not Allow
Please list any/all activities that you do not want your Camper to participate in:
I AGREE THAT BY SIGNING BELOW, I CERTIFY THAT THE ABOVE HEALTH HISTORY PROVIDED IS ACCURATE TO THE BEST OF MY KNOWLEDGE. IN ADDITION, I AM ALLOWING MY CHILD TO PARTICIPATE IN ALL CAMP ACTIVITIES PROVIDED BY BRIGHTHOUSE DAY CAMP, UNLESS NOTED ABOVE. I am giving permission to Brighthouse Day Camp to administer medications for my child as listed above on the "medical authorization form", In addition, I understand that all medications listed on the medical authorization sheet (if provided) will be only be administered if the medicine is in the original packaging and clearly labeled. Additionally, I, hereby agree to allow Brighthouse Day Camp to seek medical treatment including ordering x-rays and/or routine tests in the event of an emergency and agree to the release of any/all records necessary for treatment and to arrange for necessary related transportation for my child in the event that i cannot be reached. I hereby give permission to the physicial selected by the camp to secure and administer treatment, including hospitalzation for the person named above. (All forms compteted may be photo copied for trips out of camp). I understand the procedures for suspecting and reporting child abuse/neglect, and that Brighthouse Day Camp is legally obligated to report any/all suspicions to the appropriate authorities.
Your Name
Your Name
Your Name

WE LOOK FORWARD TO HEARING FROM YOU!

FILL OUT THE SHORT FORM BELOW

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