Camp / Clinic Programs Medical History, Treatment Permission And Release
ADVERTISEMENT
1
2
32015 MEDICAL FORM
CAMP / CLINIC PROGRAMS
MEDICAL HISTORY, TREATMENT PERMISSION AND RELEASE
Note: This form is required prior to participation in sport camps or clinics. Participation will not be permitted until this form has
been completed and signed and is on file with the sports camp.
PLEASE PRINT USING BLACK INK
□
□
□
□
SPORT:
ATHLETIC DEVELOPMENT
ALL SPORTS
BASEBALL
BASKETBALL
□
□
□
□
□
□
□
FIELD HOCKEY
FOOTBALL
GOLF
SOCCER
TENNIS
VOLLEYBALL
OTHER
CAMP NAME: _________________________________________________________ CAMP DATE(S): ____________________
PARTICIPANT INFORMATION:
NAME: ______________________________________________________
AGE: _______ DATE OF BIRTH: ___________
First
Middle
Last
HOME ADDRESS: ______________________________________________ _______________________
_____
______
Street Address
City
State
Zip
EMERGENCY CONTACT INFORAMTION:
1. NAME: _____________________________________________________________________ RELATIONSHIP: _____________
PHONE Home (______) _____________________ Work (______) ___________________ Cell (______) _________________
:
2. NAME: _____________________________________________________________________ RELATIONSHIP: _____________
PHONE Home (______) _____________________ Work (______) ___________________ Cell (______) _________________
:
HEALTH INSURANCE INFORMATION:
FAMILY PHYSICIAN:____________________________________________
PHONE: (_____) ____________________
INSURANCE COMPANY:_________________________________________
ID NUMBER:_______________________
MEDICAL HISTORY (Please use back of this sheet if necessary) DATE OF LAST TETANUS BOOSTER:_______________
Please identify any medical condition that would require special attention? ___________________________________________
___________________________________________________________________________________________________________
Is the participant under the care of a provider for a medical and/or psychological problem?
NO
YES
If yes, please explain: __________________________________________________________________________________
Is the participant taking medication prescribed by a health care provider?
NO
YES
If yes, please explain: __________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Cobb County School District "blanket" Permission To Participate Form/medical History Permission And Release Form/etc.
Legal
Child Care Subsidy - Camp/recreation Programs Agreement Between Parent/guardian And Licensed Child Care Program/home Child Caregiver
Legal
Parent Or Legal Guardian Permission And Release Form For Minor To Use Firearms And Ammunition In California
Legal
Diocese Of St. Augustine Parent Permission And Release Of Liability Parish Field Trip Participation
Business
Related Categories
Parent category: Legal