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House of Prayer/Canal Lake Bible Camp

2009 Medical Release and Liability Waver

Emergency Contact and Medical Information

Child’s Name ________________________ Date of Birth ____________________ Sex M F

Parent’s/Guardian’s Name ______________________________________ Parent’s/Guardian’s Name _______________________________________

Home Phone ___________________ Work Phone_________________ Home Phone____________________ Work Phone ___________________

Address_____________________________________________________ Address _____________________________________________________

City, ST ZIP Code ____________________________________________ City, ST ZIP Code _____________________________________________

Alternative Emergency Contacts

Primary Emergency Contact ____________________________________ Secondary Emergency Contact ____________________________________

Home Phone ___________________ Work Phone_________________ Home Phone____________________ Work Phone ___________________

Address_____________________________________________________ Address _____________________________________________________

City, ST ZIP Code ____________________________________________ City, ST ZIP Code _____________________________________________

Medical Information

Hospital/Clinic Preference___________________________________________________________________________________________________

Physician’s Name _____________________________________________ Phone Number ______________________________________________

Insurance Company ___________________________________________ Policy Number ______________________________________________

Allergies/Special Health Considerations _______________________________________________________________________________________

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or pre-
scribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the
event that neither parent/guardian can be reached in the case of an emergency.

Parent’s/Guardian’s Signature _____________________________________________________ Date ____________________________________

I give permission for my child to attend events, both on the campus and away. I release House of Prayer/Canal Lake Bible Camp, and all individuals
from liability in case of accident during activities related to House of Prayer/Canal Lake Bible Camp.

Parent’s/Guardian’s Signature _____________________________________________________ Date ____________________________________

Witness Signature _______________________________________________________________ Date ____________________________________

House of Prayer Interdenominational Church
Canal Lake Bible Camp
2925 Pat Colwell Rd. • P.O. Box 1475 • Blairsville, GA 30514 • 706-745-5925
www.houseofprayerblairsville.com