Microsoft word - med form _new_.doc

This form must be completed and returned in order to participate in the sports camp
Name of Camp__________________________________ Male______ Female_____ Dates of Camp________________________________ Participant’s Name________________________________ Soc. Sec. #_________________________ Date of Birth_____________________ Address____________________________________________________________________________________________________________ Home Phone ______________________________________________ Email Address ____________________________________________ Mother’s Name____________________________________________ Mother’s Day Phone________________________ Mother’s Evening Phone_______________________ Mobile_______________________ Father’s Name_____________________________________________ Father’s Day Phone________________________ Father’s Evening Phone________________________ Mobile________________________ Emergency Contact’s Name_________________________________ Relationship______________ Phone____________________________ Insurance Coverage:
Company______________________________________________________ Group_______________________________________________ Policy Number______________________________________ Phone Number of Insurance Company_________________________________ Policy Holder and Social Security #______________________________________________________________________________________ If there is a known history, please circle:
Dizziness/Fainting Diabetes/Hypoglycemia Other:_______________________________________________________________________ Please list any additional allergies or other health-related problems:______________________ Note: Only medications listed on this
form may be taken by the minor while at
____________________________________________________________________________ camp unless prescribed by the university’s ____________________________________________________________________________ infirmary physician. All medications should be brought in the original Date of Most Recent Tetanus Immunizations?_______________________________________ administered as directed on bottle unless Allowed medication – circle all that apply to your child:
the university’s infirmary by the nurses on My child is on the following prescription or over the counter medication (list medication and dosage)_____________________________
I certify that within the past year, the aforementioned participant has had a physical examination by a licensed physician, and that
he/she is physically able to participate in the sports camp/clinic activities.
In the event of an injury, illness, and/or accident involving my son/daughter, I hereby give my consent for medical treatment(s) at
Campbell University Student Health Services. Also, I hereby give my consent to a certified athletic trainer and/or his/her designee to
render and supervise on-site first aid treatments, to the appropriate camp/clinic personnel to properly transport my son/daughter to an
appropriate medical facility for care, and to a licensed physician to hospitalize and secure proper treatment(s), including injections,
diagnostic procedures, anesthesia, surgery, and/or other reasonable and necessary procedures for my son/daughter. I hereby
authorize my health insurance company to pay for benefits for the cost of such treatment(s). I also authorize the disclosure of medical
information to my insurance company for the purpose of any claim.
PARENT/LEGAL GUARDIAN’S SIGNATURE:_________________________________________________________________________



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