Auburn University Youth Program/camp Medical Information And Release Form (Page 2 of 2) in pdf

Company Name / Address

Policy #

PLEASE ENCLOSE A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD WITH THIS FORM

For the following, circle appropriate response and explain as appropriate:

Does participant have any limiting medical conditions that you or your doctor feel would limit camp participation?

YES NO

If yes, identify and explain:

Is participant currently taking medication that may interfere with ability to safely participate in Program?

YES NO

If yes, please indicate the medication and the condition being treated:

Does participant have a history of allergies or reactions to medications, insect stings, or plants?

YES NO

If yes, please explain:

Does participant have a history of, or currently suffer from, medical condition(s) with which we need to be aware?

YES NO

If yes, please explain:

PART 3: AUTHORIZATION FOR MEDICAL CARE

Unless prior arrangements have been made, medical needs will be handled through the East Alabama Medical Center. In

cases where medical attention is necessary, parents will be contacted for approval when possible. However, before

medical treatment can be provided, we are required to have a medical release signed by the parent/guardian. The hospital

will not perform services unless this form is presented at the time of treatment.

Participant has my permission to receive medical attention in the event of illness or medical emergency while

participating in this Program. I will assume the financial responsibility for any cost of health care for my child that may

occur during this Program.

As a participant, parent, or guardian I understand and acknowledge that my failure to disclose relevant information may

result in harm to Participant and/or others during this Program. By signing my name I represent and warrant that I have

provided all materials and important information to Auburn University pertaining to my Participant’s medical, mental and

physical condition and that it is accurate and complete. I agree to notify Auburn University of any changes in my mental,

physical or medical condition prior Participant’s scheduled Program.

By revealing or disclosing the above medical information it will not be used by Auburn University personnel or

employees to determine Participant’s ability to participate safely in activities. I understand that, if Participant chooses to

participate in activities, he/she do so voluntarily and of his/her own accord and the final decision regarding participation is

solely the responsibility of myself and Participant.

Participant Name

Parent/Guardian Name

Participant Signature

Parent/Guardian Signature

Date

A PARENT OR GUARDIAN MUST SIGN THIS FORM FOR A MINOR UNDER THE AGE OF 19

Auburn University Youth Program/camp Medical Information And Release Form Page 2