Copyright Circle J Retreat Camp. All rights reserved.
United Methodist Circle J Ranch, Inc
an affiliated organization of the Yellowstone Conference of the United Methodist Church, a 501(c)3 organization.
3338 Hwy 16 E
Ten Sleep, Wyoming 82442
Health History Form
The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.
Emergency Authorization-I hereby give permission to medical personnel selected by the participant’s Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for my child. In the event of an emergency and neither the secondary contact nor myself can be reached, I hereby give permission to the physician selected by the participant’s Church sponsor/his designee or camp staff to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery for my child as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do herby, release the below named event, its directors, employees, or agents from liability associated with participation in the below named event.