Last. First. Middle. Home Address ... Street. City. State. Zip. Home Phone. _____. Work Phone ... Personal Physician. Ph
Milford High School Conditioning Camp 2015 Enrollment Form The Milford High School Conditioning Camp is being offered once again to students that are currently in grades first through seventh. The purpose of the camp is to provide an atmosphere of physical challenges through team and individual activities. Participants will be supervised by varsity and junior high football staff members to promote a fun and rewarding experience. Camp will be conducted on Mondays, Tuesdays and Thursdays from 6:30 p.m. to 7:30 p.m. Camp begins Tuesday May 26th lasting 22 sessions through Tuesday, July 14th. Participants will meet at Eagle Stadium. If you have any questions please contact Mike Robinson at
[email protected] or Shane Elkin at
[email protected]. Full tuition must accompany this application. Please send completed Enrollment Form and Medical Report/Release along with a check or money order in the amount of $20.00 payable to the “Milford Athletic Boosters Club” (“Conditioning Camp” on memo line) to: Head Football Coach Shane Elkin, Milford High School, One Eagles Way, Milford, Ohio 45150. Please complete the following information for each child to enroll in the camp: Name_________________________
Current Grade _______
(Please circle shirt size) Adult Shirt Sizes: XXXL
XXL
Youth Shirt Sizes: XL L
M S
XL
L
M
S
I, the undersigned submit that my son, daughter, or ward is physically fit to participate in strenuous athletic activity and release the Coaching Staff, Milford Schools, and all sponsors from any and all claims, liability, causes of action, losses and damages resulting from or arising out of injury, illness or property damage to my son, daughter or ward. I hereby authorize the directors of the camp to act for me according to their best judgment in an emergency requiring medical attention. I understand that I am solely responsible for the payment of any such medical expenses and that I am responsible for providing the information needed on the camp medical form. I consent to the camp and the camp photographer taking and / or using photographs of my son, daughter, or ward for promotional or marketing purposes. Parent/Guardian Signature _________________________ Date ___________ Grades 1-7 fee is $20
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Milford High School Conditioning Camp Medical Report/Release (Please Print) Name (Print) _______________________________________________________________________ Last
First
Middle
Home Address ____________________________________________________________________ Street
City
State
Zip
Date of Birth _____________________________________ Current Grade _____________________ Mo/Day/Yr
*********************************************************************************************************************
Parent/Guardian Information
Relationship _____________________________
Name (Print) _______________________________________________________________________ Last
First
Middle
Home Address _____________________________________________________________________ (If different)
Street
City
Home Phone
_____
Cell Phone
Work Phone
Zip
___________________
___
_______________
If above person is unavailable, contact Telephone
State
_____in case of emergency.
_____________
********************************************************************************************************************** Personal Physician Insurance Carrier
Phone
__________
Policy # ___________________________
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* Is Camper now under treatment for any medical or psychological condition?
Yes
No
If yes, please explain: _____________________________________________________________ _______________________________________________________________________________
* Please list any daily and routinely taken medications of which the Camp Staff should be aware. _______________________________________________________________________________ _______________________________________________________________________________
* Does Camper have allergies to medications or other sensitivities? If yes, please explain.
Yes
No
_______________________________________________________________________________
* Does Camper have any other special health care concerns of which the Camp Staff should be aware? Yes
No
_______________________________________________________________________________ _______________________________________________________________________________
********************************************************************************************************************* I hereby grant permission to the staff of the Milford High School Conditioning Camp and the Athletic Trainer of Milford High School to arrange for health care, emergency treatment, or hospitalization at an accredited hospital or other medical, psychological, or dental care facility when considered necessary. I also grant permission to the staff of the Milford High School Conditioning Camp and the Athletic Trainer of Milford High School to render any health care or emergency treatment needed to my son/daughter/ward.
Date
Signature _______________________________________ Parent /Guardian
