IS THERE ANY REASON WHY PARTICIPATION SHOULD BE LIMITED IN ANY WAY? yes no. HEALTH HISTORY: Asthma: Yes/No. Loss of Limb
Camp Location _______________________ Camp Dates or Session ___________________
PREMIER SPORTS CAMPS, Inc.
EMERGENCY INFORMATION AND PHYSICAL EXAMINATION FORM . NAME______________________________ DATE OF BIRTH ______________ AGE__________ SPORT ______________________________ ADDRESS ___________________________ CITY ____________________ STATE ______ ZIP__________ PARENTS (Guardian) NAME ___________________________PHONE ___________________ Emergency Phone numbers during day _____________________________________________ If Parents cannot be reached, please contact ____________________________Phone _____________ PLEASE NOTE ANY SPECIAL OR MEDICAL CONDITIONS (Allergies, Asthma, Etc.) OF WHICH WE SHOULDBEAWARE________________________________________________________________________________________ ____________________________________________________________________________________________________________ LIST ALL PREVIOUS HOSPITALIZATIONS__________________________________________________________________ LIST ANY MEDICATIONS CURRENTLY BEING TAKEN______________________________________________________ ARE ALL IMMUNIZATIONS UP TO DATE?
yes
no
Date of last tetanus______________________________
IS THERE ANY REASON WHY PARTICIPATION SHOULD BE LIMITED IN ANY WAY? yes
no
HEALTH HISTORY:
Asthma: Yes/No Loss of Limb: Yes/No Ear Infection: Yes/No Diabetes: Yes/No Orthopedic Problem: Yes/No Tuberculosis: Yes/No Heart Problem: Yes/No Depression: Yes/No Cancer: Yes/No Mono: Yes/No Head Injury: Yes/No Migraine: Yes/No Please explain all “yes” answers________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ I, the undersigned parent (guardian), do hereby authorize the athletic trainer , physician, nurse or their designate at the camp to secure any and all necessary medical treatment. I understand that the School/University and Premier Sports Camps will attempt to contact the parent before treatment is initiated. If the School/University and Premier Sports Camps cannot reach the parent, I authorize the attending physician to render any and all medical care which he/ she deems necessary.
_______________________ Date
X _______________________________________________________________ Parent’s Signature
HEALTH INSURANCE INFORMATION: Carrier Name: __________________________________________________ Policy Holder Name:_____________________________________________ Policy Number: _________________________________________________ Policy Holder Date of Birth: ______________________________________
PREMIER SPORTS CAMPS, Inc. Medical Form Page 2 – Physician’s Examination
In addition to the above information, each camper must have 1 of the following: •
A physical examination conducted within 1 year of the first day of camp signed by a physician (attached and brought to the first page above)
•
A State Qualifying school physical (attached and brought to the first page above)
•
The below Waiver signed by a parent (attached and brought to the first page above)
** If camper will be arriving with someone other than parent, all information must be complete
PREMIER SPORTS CAMPS MEDICAL RELEASE FORM - WAIVER
The following camper,
, did not have a completed physical form
when reporting to camp on
. As his/her parent or legal guardian, I certify that
is in good health and is able to participate in all camp activities. I take complete responsibility for the health of this camper while he/she is attending Premier Sports Camps.
Parent / Guardian Name ________________________________________ Signature
