|
HEALTH AND RELEASE FORM
* BRING THIS FORM TO CAMP *
(You will not be admitted to camp without this completed form)
Camp Location_________________________Camp Dates____________________
Campers Name________________________Age________Wt.________Ht.______
HEALTH AND GENERAL HISTORY
If the camper should be restricted from any activity please note:___________________
___________________________________________________________________
Please identify any medical condition or history, which would require special attention:
________________________________________________________________________ I hereby certify the named camper is physically able to participate in he Sports Camp and that I know of no restrictions, physical impairments, or any other facts which in any manner limit his participation in such a program._______________________________
Dr. Signature ___________________________ Date of Physical_____________
(required for NY Camps only)
Has the camper had?
IMMUNIZATIONS ALLERGIES DRUG REACTIONS
(Include dates) (Yes/no) (Yes/no)
Tetanus Toxoid _____ Hay Fever _____ Sulpha _____
Poliomyelitis _____ Asthma _____ Penicillin _____
Tuberculin Test _____ Eczema _____ Antibiotics _____
MMR _____ Insect Stings _____ (type)_____________
Chicken Pox _____ Other ___________ Other ____________
Mumps _____ _________________ _________________
Diptheria _____ _________________ _________________
Physicians Name ____________________________________________________
Physicians Address__________________________________Phone ____________
INSURANCE INFORMATION
Carrier Name__________________________Policy Number____________________________
Policy Holder Name________________________Policy Holder Date of Birth________________
I, the parent of________________________, give permission for my child to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that every attempt will be made to contact me, or the named person below, before taking this action. I hereby waive and release the Staff, Camp Management and Owners from any liability for an injury or illness incurred while at camp. I UNDERSTAND THAT THERE IS A RISK OF INJURY TO MY CHILD AS A RESULT OF CAMP ACTIVITIES AND KNOWLINGLY AND VOLUNTARILY ASSUME ALL RISK OF SUCH INJURY. I will be financially responsible for any medical attention needed during camp or resulting from an injury received at camp. My medical insurance shall be the insurance coverage for any medical treatment.
(Sign)__________________________________Date________________________
Home Phone________________________Work Phone_______________________
Phone Number while my child is at camp (if different)__________________________
Person to contact in the event I cannot be reached____________________________
Phone number of emergency contact person_________________________________
Bring or Send to: Coach Pilat, Roanoke College, Salem, VA 24153
|