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Microsoft word - release form.docxAll information provided on this form is correct to the best of my knowledge. In case of emergency or illness, I understand that every effort will be made to contact the Emergency Contact for my child(ren). I give Colorado Christian Service Camp (Camp Como) permission to seek medical treatment for my child(ren) in case of emergency. I give Camp Como medical staff permission to provide my child(ren) with medical treatment which may include, but is not limited to: the use of Tylenol, Ibuprofen, Benadryl, Rolaids, Cough Medicine, Chlorpheniramine (allergy med), Benadryl Cream, Caladryl, Triple Antibiotic Ointment, Pseudofed, Claritin, or generic equivalents to these medications, physician consultation, urgent, emergent, and non-emergent medical treatment. I understand that the private health information on this form will only be used and shared for the purposes of medical treatment. I agree to indemnify and hold harmless Camp Como and its leaders, staff, elders, employees, members, agents, vehicle owners, vehicle drivers, trip sponsors, board of trustees, and any other parties volunteering on behalf of the camp from any and all claims, damages, losses, injuries and expenses arising out of or resulting from my child(ren)’s participation in Camp Como activities. Please note any exceptions to treatment: I give permission for my child(ren), __________________________________, to attend and participate in activities sponsored by Colorado Christian Service Camp (Camp Como). I understand that these activities are at a high elevation, may include physical activities, and may require transportation. I hereby give my consent for my child(ren) to participate in said activities. In consideration of my child(ren) being allowed to participate in activities sponsored by Camp Como, I do, for myself and on behalf of my child(ren), release, forever discharge, and agree to hold harmless Camp Como, its leaders, staff, elders, employees, members, agents, vehicle owners, vehicle drivers, trip sponsors, board of trustees, and any other parties volunteering on behalf of the camp, from any and all liability, claims, damages, suits, fees, and costs incurred by the undersigned and the child(ren) that occur while the child(ren) is at Camp Como participating in or participating in any activity that is sponsored by Camp Como. _________ (Initialize) I realize that my child(ren) may incur personal injury or bodily damage while participating in such activities and acknowledge that many of the activities will be physical in nature and will include travel. I, on behalf of my child(ren), hereby assume all risk of personal injury, sickness, death, damage, and expenses as a result of participating in all activities involved therein. I acknowledge that Camp Como, its leaders, staff, elders, employees, members, agents, vehicle owners, vehicle drivers, trip sponsors, board of trustees, and any other parties volunteering on behalf of the camp, shall be held harmless from any and all actions, claims, costs, expenses, and damages of any kind, growing out of or related to any activity of the camp in which my child(ren) participates. I further acknowledge that this is a full and complete release for all injuries, sickness, death, limitations, and damages which my child(ren) could sustain as a result of his/her/their participation in any camp activities. I further agree to hold harmless and indemnify the camp, its leaders, staff, elders, employees, members, agents, vehicle owners, vehicle drivers, trip sponsors, board of trustees, and any other parties volunteering on behalf of the camp for any and all liability sustained by the church and camp as the result of the negligent, willful or intentional acts of my child(ren), including expenses incurred. _________ (Initialize) 4. MEDICAL RELEASE AND CONSENT TO EMERGENCY MEDICAL TREATMENT I authorize the camp and group leader(s) or camp medical personnel, in whose care my child(ren) has been entrusted, to consent to any X-Ray examination, diagnosis and/or treatment (i.e. anesthetic, medical, surgical, or dental), or hospital care to be rendered to my child(ren) under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether diagnosis or treatment is rendered at the office of physician or the hospital, I shall be liable and agree to pay all costs and expenses incurred in connection with such medical/dental services rendered. This authority is granted only after a reasonable attempt has been made to contact me or in a life-threatening situation. _________ (Initialize) I have read and agree to all of the above provisions. Signed: ___________________________________________________ Date: ____________________ (Parent/Legal Guardian) Witness: ____________________________________________________
Adult dose Pediatric dose Comments Contraindications/ Precautions travel, then daily and for 7 with severe renal impairment should be taken with food women, and women only in areas chloroquine- sensitive P. falciparum retinopathy not seen in malaria prophy doses same day of the until for 4 SE: gastrointestinal only in areas chloroquine- sensitive P.