Auburn University Youth Program/camp Medical Information And Release Form
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2Auburn University
Youth Program/Camp Medical Information and Release Form
PROGRAM/CAMP INFORMATION
Program/Camp Name:
(hereafter “Program”)
Date(s):
Time(s):
Location:
As a student, parent or guardian I understand that the information requested on this form is intended to help inform program staff
of any pre-existing medical conditions. If Participant has a pre-existing medical condition, participation in any strenuous activities or
recreational time may not be recommended. This information will be kept in strict confidence and will only be shared with your
permission. Auburn University requests the information below so that, in case of emergency, we will have accurate information so
that we can provide and/or seek appropriate treatment for Participant. You are accountable for providing an accurate medical history.
Final determination about whether to participate is the responsibility of you and your physician. If Participant has any medical
issue that is not requested below, but which you think is important, please include that information. It is recommended that you
consult with a physician prior to participating in this Program. If you are uncertain about any preexisting medical conditions, it is your
responsibility to consult with your own physician prior to participating in this Program. Please answer all of the questions. If you
answer yes to any of the following questions, please explain as indicated. Use back and/or additional paper if needed.
I understand that Auburn University does not offer any form of insurance for participant while participating in Program.
PART 1. GENERAL INFORMATION
Participant Name
(hereafter “Participant”)
Parent/Legal Guardian Name (if applicable)
Street Address
City
State
Zip
Home Phone
Work Phone
Date of Birth
/
/
Gender
M
F
Please list two emergency contacts:
Emergency Contact #1 Name
Home Phone #
Work Phone #
Cell Phone #
Relation
Emergency Contact #2 Name
Home Phone #
Work Phone #
Cell Phone #
Relation
PART 2. MEDICAL INFORMATION
It is recommended that Participant consult with your physician prior to participating in this Program. If you are uncertain about any
preexisting medical conditions, it is your responsibility to consult with your own physician prior to participating in this Program.
Please answer all of the questions. If you answer yes to any of the following questions, please explain as indicated. Use back and/or
additional paper if needed.
Physician’s Name
Phone Number
Date of most recent tetanus toxoid immunization
Do you have health/accident insurance? (circle one):
YES
NO
If yes, please indicate policy number, name and address of insurance company.
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