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____________________________ 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__________________
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