Camp Medical Release / Authorization Form
Doctor Information
Doctor's Name:
Doctor's Address (Street, City, State & Zip Code):
Doctor's Phone #
Group #
Gymnast / Camper Information
First Name:
Last Name:
Birth Date:
Which week of Camp(s) are you attending?
Your Insurance Carrier
Digital Signature:
Comments:
Contact Information
First & Last Name:
Primary Phone #
Email:
Policy #
In the box below,

Please tell us what medication you will be providing and when you would like your child to receive their dosage:
Medical Information
If it is necessary for your child to receive medication during the camp day, please do the following:

1. Send the medication to camp with a responsible individual (if you are unable to bring it) and give it to the camp coordinator.
2. Send the medication in the original container, properly labeled with the original pharmacy dosage information.

Please list all medications Child is currently taking:
This form is being completed by:
Emergency Contact Information
In Case of Emergency, Please Contact:
First & Last Name:
Primary Phone #
Relationship:
First & Last Name:
Primary Phone #
Relationship:
In case we cannot reach your primary Emergency Contact,
Please Provide a Secondary Contact:
By digitally signing this document below, I understand and give permission for Olympiad Gymnastics to arrange for emergency medical/surgical/dental care and treatment (including diagnostic procedures) necessary to preserve the health and well being of my child.  I acknowledge that I am responsible for all charges in connection with any care and treatment rendered.
I give permission to the personnel of Olympiad Gymnastics to dispense the above medication to my child according to my instructions provided.

I understand that Olympiad Gymnastics will NOT assume any responsibility for accidents and/or medical and/or dental expenses received as a result of participation in the camp.

In the event Olympiad Gymnastics cannot reach any of the emergency contacts provided, I give my permission to give whatever immediate treatment is necessary and/or take my child to the Christiana Hospital or A.I. Dupont Children's Emergency room.

Due to the strict licensing requirements for Olympiad Gymnastics, we are obligated by the state of Delaware to have on file current immunization records for all campers attending our camp.  You must provide a photocopy of your child's immunization records that indicate they are up to date on the following shots; Diphtheria, Rubella, Measles, Tetanus, & Mumps.
I understand that no reduction in the tuition will be made for late arrival or early departure.

I hereby release Olympiad Gymnastics and its personnel from any and all claims that occur during camp.

Permission is hereby granted for photographs and or videos to be taken of my child at camp.  Photos may be used in marketing materials and/or posted online on sites like Facebook, You Tube and our website to be shared with you and others online.  Olympiad has the right to use images in the use of marketing, brochures and other advertisements.

Permission is also granted for my child to attend all scheduled field trips, swim sessions, and be transported in Olympiad designated vehicles.

There are NO refunds or exchanges.
Release & Policies
Copyright 2011: Olympiad Gymnastics. Delaware Gymnastics. All Rights Reserved.
380 Water Street, Wilmington / Newport DE 19804
302-636-0606  |   Office@FlipKidz.com
I have read and agree to all terms for camp 
I understand & permit 
I understand, agree & will comply