MEDICAL RELEASE FORM
COERVER® Coaching of Colorado
P.O. Box 4946
Englewood, CO 80155
E-MAIL: [email protected]
Date of Birth
Street, City, State & Zip
Emergency Contact Person
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.
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