Parental/guardian Permission And Medical Release (Page 2 of 2) in pdf

Parental/guardian Permission And Medical Release Page 2

CONTACT INFORMATION:

Emergency Contact:___________________________

Phone:_______________

Alternate Emergency Contact:________________________

Phone:_______________

Physician Contact: ___________________________

Phone:_______________

Medical/Hospital Insurance: Carrier

:__________________________________

Policy Number: _______________________________________________

Adult name on policy: __________________________________________

Please check-off any of the following injuries or illnesses your child has had:

Chicken Pox

Head Injury

Ankle Injury

Asthma

Convulsions

Heart Condition

Diabetes

Frequent Ear Infections

Back Injury

Knee Injury

Fainting Spells

Other

PLEASE MAIL THIS COMPLETED FORM AND BRING A COPY WITH YOU TO CHECK-IN.

Please record any food, medication or other allergies camper has:

What medication will this camper take while at Camp?

Medicine________________ Dosage_________ Specific times taken each day___

Reason___________

Please record any medical or surgical history this camper has, and whether she has

been hospitalized or has visited a doctor for an illness during the past year:

Is there any other health-related information or suggestions that may help ensure this

camper‘s health and safety while at Camp?

IMPORTANT: MANDATORY INFORMATION

ALL CAMPERS MUST PROVIDE THE FOLLOWING PRIOR TO THE START

OF CAMP:

CURRENT PHYSICAL EXAMINATION (must be within 12 months of

camp dates)

IMMUNIZATION VERIFICATION

All forms must be signed by a licensed health care provider. These forms must be on

file with the Camp Director three weeks prior to the start of camp. All forms are

required by the Department of Public Health.

MAIL INFORMATION TO:

PRECISION SOCCER, LLC

P.O. Box 59

Wilmington, MA 01887

Thank you for your cooperation

Parental/guardian Permission And Medical Release Page 2

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