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Colorado Medical Release Form 3

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This form is provided by Coerver Coaching of Colorado for the medical information release regarding the medical care and treatment necessary to be administered to the camper.

Colorado Medical Release Form 3
Colorado Medical Release Form 3
MEDICAL RELEASE FORM
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 Cell Phone
Emergency Contact Person Phone
My Insurance Company is:
Policy or Group Number:
Our Physician is: Phone
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) Date
Colorado Medical Release Form 3