Health History  & Medical Release Form

City of Darlington or their representative for this event, has my permission to secure emergency medical
treatment for my child _____________________________ while participating in this Summer camp.

Insurance Carrier:_____________________________________________________

Policy Number:_______________________________________________________

SS# of policy holder:___________________________________________________

Signed:______________________________________________________________
                              Parent/Guardian                                Date


Known Allergies:



My child is taking the following medications (please list medication, dosage, and times taken and any storage
instructions).



Please provide any additional information you think would enhance your child’s time while participating in this
camp.



I give my permission for the adult in charge to provide over the counter medication. Please specify type.














Signature   ____________________________________________________________