Health Form for All Camps (Except Camps held in New York)  ____________________________  Camp Name                            _____________________________    Camp Dates First Name____________________________M.I.:______ Last Name_______________________________________ Home Address__________________________________________________________________________________ Age _________Birth Date __________Date of last tetanus shot _________Do you wear glasses/contact lenses? ______ Emergency Contact #1 _________________________________________Relationship_________________________ Home Telephone # ___________________Work # ________________________ Cell # ________________________ Emergency Contact #2 _________________________________________Relationship_________________________ Home Telephone # ___________________Work # ________________________ Cell # ________________________ Describe treatments you are receiving for current illness/conditions (incl. chronic illness i.e. asthma, diabetes, seizures) ______________________________________________________________________________________________ ______________________________________________________________________________________________ List any allergies (e.g.: insect stings, food, medication, etc.) ______________________________________________________________________________________________ ______________________________________________________________________________________________ List any medications you are currently taking ______________________________________________________________________________________________ ______________________________________________________________________________________________ PERMISSION TO TREAT I give permission for 1) Roanoke College employees to administer first-aid to me in the event that I am unconscious or otherwise unable to give consent;   2) medical personnel to treat me in the event that I am unconscious or otherwise unable to give consent;  3) Staff members of Bill Pilat’s Lacrosse Camps, Inc.  to administer first-aid to me in the event that I am unconscious or otherwise unable to give consent;   _______________________                        _________________________                        _________________ (printed name)                                                                 (signature)                                                     (Date) _______________________                        _________________________                       _________________ (printed name of Guardian if under 18)                                 (Signature)                                               (Date) INSURANCE INFORMATION  Carrier Name____________________________________Policy Number___________________________ Policy Holder Name______________________________Policy Holder Date of Birth__________________