Medical Release and Permission Form

Medical Release Form

This form is to be completed by a parent/legal guardian of the participant. All information will be kept in a secure file during the 2023 TUMB Summer High School Marching Arts Camp, and will only be used in case of an emergency.

Name of Parent/Guardian Completing Form

Email of Parent/Guardian Completing Form *

Participant Name, Age, and DOB

Participant First and Last Name *

Participant Date of Birth *

Participant Age *

Participant Health Insurance Information

Health Insurance Company *

Insurance Policy Number *

Name on Insurance Policy *

Additional Emergency Contact

In the event of an emergency and the Parent/Guardian listed in the camp application is not available, please use the space below to indicate another emergency contact.

Additional Emergency Contact First and Last name *

Additional Emergency Contact Phone #1 *

Additional Emergency Contact Phone #2

Participant Medications and Dietary Information

Non Prescription Drugs *

Yes

No

Medical Devices *

Yes

No

Please list and explain participants medical devices: *

Dietary Restrictions *

Yes

No

Note: All dietary information will be shared with TU Dining Services in order to make the necessary accommodations. Participants will be dinning in a buffet style dining hall with numerous options.

Please explain participant dietary restrictions: *

Medications

Special Instruction

Allergies

Limited Activity

Parent/Guardian Authorization

Please review the below statements and mark the applicable response.

I give my permission for photographs or video footage of my child to be used by TUMB Summer Band Camps for promotional purposes:

Media Consent *

I Agree

I Disagree

I agree to indemnify, release, and hold Towson University and the TUMB Summer High School Band Camp, the Commonwealth of Maryland, and their respective officers, agents, employees, and volunteers from any and all costs, liabilities, expenses, claims, compensation, demands, or causes of action on account of any loss or damage to personal property of the aforementioned child arising out of or in connection with his/her participation in the TUMB Summer High School Band Camp and related activities.

Waiver of Liability *

I Agree

I give permission for the directors and staff of this program to secure emergency medical care for my child if there is insufficient time to contact me.

Medical Release *

I Agree

Medical Release Form

This form is to be completed by a parent/legal guardian of the participant. All information will be kept in a secure file during the 2023 TUMB Summer High School Marching Arts Camp, and will only be used in case of an emergency.

Participant Name, Age, and DOB

Participant Health Insurance Information

Additional Emergency Contact

Participant Medications and Dietary Information

Note: All dietary information will be shared with TU Dining Services in order to make the necessary accommodations. Participants will be dinning in a buffet style dining hall with numerous options.

Parent/Guardian Authorization

Please review all answers for accuracy before submitting.