Mission + Purpose
The Power Of Camp
Cabin Sublet Form
Medical Consent Form
Indicates required field
Child's Date Of Birth
Emergency Contact Info
Emergency Contact Name
Emergency Contact Number
Physician Phone Number
Medications must be in their original bottle and within date.
Medications your child will take at camp (Please provide medication name, dose, and time of day the medication should be taken):
Please check each over the counter medication that you are ok for your student to receive while at camp:
Chloraseptic Throat Spray
Allergies, if any (including medications):
Date of last tetanus booster:
Has your child had any surgery? If yes, please list:
Chronic or existing diseases or medical problems:
Medical Insurance Info
The policy of the camping program states that in case of an accident that requires doctor or hospital care, the family insurance coverage is the primary coverage and the camp’s insurance is the secondary.
Medical Insurance Carrier
By submitting this form, I authorize healthcare personal to treat the above child in an emergency while attending and being cared for by the Fairmount Camp staff during the registered camp. I also authorize Fairmount Camp to administer my child’s daily medications and the checked over the counter medications.
Basic treatments such as saline eye drops, cough drops, calamine lotion, triple antibiotic ointment and Vaseline may be administered by camp staff as needed.
711 E 900 S (State Road 26) Fairmount, IN, 46928 | P: