Colorado Medical Release Form 3
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COERVER® Coaching of Colorado
P.O. Box 4946
Englewood, CO 80155

E-MAIL: [email protected]

PHONE: 720-255-4911

Camper Name

Date of Birth

Street, City, State & Zip
Home Phone

Business Phone

Emergency Contact Person

Cell Phone

My Insurance Company is:
Policy or Group Number:
Our Physician is:


Should the Camper be restricted in any way? Please describe in the space below.

Medications which Camper is bringing to Camp.

I hereby grant my permission to administer, and accept any financial responsibility for any and all medical
attention necessary to be administered to my child/ward, in the event of an accident, injury, sickness, etc.,
while attending the Coerver Coaching Camp. Any representative of the Coerver Coaching Camp is
designated to act in my behalf until I have been contacted.
SIGNATURE (Parent/Guardian)


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