Camp Medical Form

This form must be completed and returned prior to participation in the program.

Your Email (required)

Player Name (required)

Birth Date (required)


Name of Parent or Guardian

Home Phone

Parent/Guardian Work Phone


Insurance Company

Policy Number

Plan Type

Co-payment (if applicable)


If parent is not available in an emergency notify:

Name

Phone

Name

Phone


HEALTH HISTORY:

Allergies Detail

Operations, Serious Illness or Injuries (provide dates)

Is the child taking any medication?


PARENT’S AUTHORIZATION

This health history is correct so far as I know and the person here-in described has permission to engage in all camp activities. In the event that I, or persons named above in case of emergency cannot be reached in an emergency, I hereby give my permission to the physician selected by the camp director to hospitalize and/or administer proper medical treatment for my child as named above. I also understand that I will be held responsible for the payment of my child’s medical bills.

Electronic Signature

Date