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Microsoft word - med form _new_.doc

CAMPBELL UNIVERSITY SPORTS CAMP MEDICAL INFORMATION
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:_________________________________________________________________________

DATE:____________________________________________________________________________________________________________

Source: http://www.ohssoftball.net/Campbell_Med.pdf

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The 4th Annual Arthur E. Imperatore School of Sciences and Arts Graduate Student Conference April 13, 2005 Hayden Hall Lounge Stevens Society of Graduate Physics Students Stevens Society of Mathematicians Graduate Student Society of Chemistry and Chemical Biology Graduate Student Society of Computer Science Schedule 8:30am-9:00am: Check in, registra

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