I request that _________________________________ (name) can be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment. I have not been given a guarantees to the results of the examination or treatment. I authorize the hospital or medical facility to dispose of any specimum or tissue taken.

 

I also authorize the CNSF to use the campers/candidates likeness or image in any future promotional material including printed, electronic or other forms. I renounce any and all claims upon CNSF or their agents for reimbursement for the use of this material.

 

Date of Birth                               _______/_______/_______

 

Date of last Tetanus Booster     _______/_______/_______

 

Known allergies including any allergies to medicine:

 

___________________________________________________________________________________

 

___________________________________________________________________________________

 

___________________________________________________________________________________

 

Any other medical problems which should be noted:

 

___________________________________________________________________________________

 

___________________________________________________________________________________

 

___________________________________________________________________________________

 

Family Physician      _____________________________________________________

 

Address                  _____________________________________________________

 

City, State and Zip  _____________________________________________________

 

Phone                     (_____)________________________ Cell (______)_____________________

 

email ____________________________________

 

Emergency Contact:

Name                        ____________________________________________________

 

Address                    ____________________________________________________

 

City, State and Zip   _____________________________________________________

 

Phone                     (_____)________________________ Cell (_____)_______________________

 

email ____________________________________

 

Insurance Information:

Carrier                         _________________________________________

 

Policy Number              _________________________________________

 

 

Date:_______________________ Signature:______________________________________________

 

Please Return to:
CNS Foundation

2208 Milburn Lane

Reston, VA 20191