Parental Consent And Waiver Of Responsibility Form
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1RICK NOLD VOLLEYBALL CAMPS
Camp____________________________
Camper Name_______________________________
Dates____________________________
PARENTAL CONSENT AND WAIVER OF RESPONSIBILITY
In consideration of Auburn University Sports Camp acceptance of ________________________________
as a student in Sports camp for the period in the dates mentioned above.
It is agreed that all risks attendant to watching and/or participating in camp activities including, but not
limited to bodily injury, are assumed by the student and his parents and/or legal guardian and that this
assumption is acknowledged, approved, and agreed to by said student and his parents and/or legal
guardians as indicated by their signature hereto. Sports Camp insurance will be financially responsible for
injuries/accidents occurring during camp, only as secondary coverage after the parent’s/guardian’s
insurance has paid.
I hereby grant permission for physicians, dentists, other licensed health care providers and their designees
to administer outpatient medical, surgical, or dental services as appropriate, or necessary antigens or other
injections, to perform emergency procedures as necessary or to refer to duly licensed medical personnel
when indicated.
_____________________________________
___________________________________
Parent or Legal Guardian Signature
Date
MEDICAL CLEARANCE
I hereby certify the named camper is physically able to participate in Auburn University Sports Camps and
that I know of no physical impairments which would in any manner limit his/her participation in such
program.
______________________________________
___________________________________
Physician’s Signature
Date
MEDICAL INFORMATION
Hospitalization Plan: Claim No._______________________ Company____________________________
City________________________State_________________ Zip Code____________________________
Phone______________________________
Medical History (if pertinent):
_____________________________________________________________________________________
Allergies, present medication, special considerations:
_____________________________________________________________________________________
Parent/Guardian________________________________________________________________________
Address____________________________City__________________State________Zip Code__________
EMERGENCY MEDICAL INFORMATION
______________________________ (___)______________________________________(HOME/CELL)
NAME
PHONE
______________________________ (___) _____________________________________(HOME/CELL)
NAME
PHONE
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