2023 Medical Form – Encore Community Music Association

2023 MEDICAL FORM

Please fill out this medical form and submit prior to camp.

Please select the correct camp:*
- Carroll County Camp (June 19-23, 2023)
- Howard County Camp (June 26-30, 2023)
Camper's Name*
First Last
Address*
Street Address City State ZIP Code
Home Phone*
Email*
Date of Birth*
MM slash DD slash YYYY
Sex*
- Male
- Female
Mother's Name*
First Last
Mother's Daytime Phone*
Father's Name*
First Last
Father's Daytime Phone*
Insurance Company*
Policy #*
Emergency Contact Name (other than parent)*
First Last
Relationship
Phone*
Does your child have any health disabilities that might impair his/her activity at camp? (Keep in mind that there will be outdoor recreation during the week.)*
- No
- Yes
If yes, please explain:
Please list any other pertinent information that might be needed at camp (i.e., allergic reactions, ADHD, etc.):
Consent*
I approve the agreement below.
I hereby authorize the staff of the Encore Summer Music Camp to act for me according to their best judgment in any emergency requiring medical attention, giving permission to have my child transported to the nearest hospital if necessary. In addition, I hereby waive and release the ECMA, its camp staff, affiliates, camp venues and organizations of any and all claims, liabilities, personal injuries, damage to property, resulting from participation in or in any way connected with the camp program. By approving this agreement, I accept and assume full responsibility for any and all injuries, damages, and losses of any type, which may occur to my child during the camp. Furthermore, I release all photos taken of my child by the ECMA staff for promotional purposes and the camp slideshow.
Date
MM slash DD slash YYYY