Summer Camp Safety Form Camper Name * First Name Last Name Who should we call in case of an emergency? List the names of the people who are allowed to pick up your child. List any prescription medications your child is taking. Please submit your Doctor's Name, Doctor Phone Number, Insurance Company, and Insurance Policy Number I authorize Lochwood Academy staff/agent to administer First Aid (including over-the-counter medicines) as required for illness and injury. The signature of the parent or guardian below is intended to serve as a medical release. I Accept I Do Not Accept In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by Lochwood Academy to hospitalize, to secure proper treatment for and/or order an injection, anesthesia, or surgery for my child as deemed necessary. I Accept I Do Not Accept As parent or guardian of above camper, I hereby agree to allow him/her to participate in all activities that occur at Lochwood Academy during Summer Camp. I realize that unanticipated and unexpected dangers may arise during and associated with the camp activities. I voluntarily agree to accept any and all risks of injury arising from the camp activities. I Accept I Do Not Accept Any other information that we need to know? I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and medical release. I am signing it of my own free will. Thank you!