Freedom Center 2025 Summer Camp Forms Packet

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MEDICAL AUTHORIZATION TO TREAT
University (conducted/managed/operated) Programs

George Mason University requests the following information so the Program staff can arrange for medical care in the event of an emergency. You are responsible for providing accurate and complete information.

Program/Camp Name:

Freedom Aquatic & Fitness Center Summer Camps

Date(s):

2025

Location:

Freedom Aquatic & Fitness Center

GENERAL INFORMATION

Participant Name:

Street Address:

City:

State:

Zip:

Phone Number:

Cell Number:

Date of Birth:

Gender:

Previous Child Day Care Programs & Schools attended:

If child attends another summer program please give name of program(s):

Grade camper will be entering in Fall:

PRIMARY PARENT/GUARDIAN NAME:

Last:

First:

MI:

Address: If different from above

Phone Numbers:

Home:

Cell:

Work:

Relationship to camper:

Email:

Employer Name:

Address:

SECOND PARENT/GUARDIAN NAME: