Edie's Retreat
2903 Rae Dell Ave

Austin, Texas  78704          

Students Name___________________________________

Parents name(s) __________________________

                         Emergency Contact #____________________________

                       
                         Physicians Name____________________________

               
                  Physicians Phone contact_______________________

Permission to seek treatment:

I/We, the undersigned, hereby certify that I (We) am (are) the parent or legal guardian of the camper.  I hereby give permission for the staff of the camp to seek during the period of the camp, appropriate medical attention to be given and for the camper to receive medical attention in the event of accident, injury, or illness.  I will be responsible for any and all costs of the medical attention and treatment.

Parent or Guardian Signature_______________________________ 

Date______________