Summer Wrestling 2012 Camps Application Form (Page 2 of 2) in pdf

BEAT THE STREETS WRESTLING MEDICAL HISTORY

SIGNED BY PHYSICIAN (OR ATTACHED PRINT OUT SIGNED BY PHYSICIAN)

NAME: LAST___________________________FIRST__________________________DATE OF BIRTH__________AGE____

PARENT/GUARDIAN NAME:_______________________________HOME PHONE #_______________________________

ADDRESS: STREET____________________________APT. #______CITY__________________________STATE_________

PARENT/GUARDIAN CELL #_________________________________ALTERNATE#/WORK _________________________

ALTERNATE/IN CASE OF EMERGENCY- NAME__________________________________RELATIONSHIP_______________

HOME PHONE #______________________________________CELL#__________________________________________

Any allergies to Medication/Food ______________________If yes, specify______________________________________________

Epinephrine Injection Pen carried_______________________Other Allergy Medications Administered_______________________

HEALTH HISTORY (circle any/all applicable): Frequent Ear Infections, Heart Defect/Disease, convulsions, Diabetes,

Bleeding/Clotting Disorders, Hypertension, Psychiatric Treatment, Mononucleosis, Asthma, Chicken Pox, Measles, German

Measles, Mumps – provide approximate date(s)____________________________________________________________________

IMMUNIZATION HISTORY/DATES: Diphtheria____________________Poliomyelitis___________________Rubella_____________

Pertussis___________________Tetanus_____________________Measles______________________Mumps___________________

Has patient ever required any psychiatric counseling or hospitalization? ____________________________________________________________

Operations or serious injuries (dates):________________________________________________________________________________________

Disability or chronic or recurring illness:_______________________________________________________________________________________

Any specific activities to be encouraged or limited by physician’s advice: ____________________________________________________________

Dietary Modifications: _____________________________________________________________________________________________________

Current medication(s) – send with instructions: ________________________________________________________________________________

Other diseases or details of above: ___________________________________________________________________________________________

Date of last full physical exam:_________________________________________Immunization Records attached___________________________

Name of Physician:_________________________________________________Office Phone #___________________________________________

Address of Physician:_____________________________________________Family Insurance Carrier Name________________________________

Insurance Carrier/Agent phone #____________________Policy or Group #_____________________Member ID #__________________________

IMPORTANT: CHOICE “A” OR “B” MUST BE SIGNED OFF ON TO ASSIST YOUR CHILD IN CASE OF EMERGENCY: Permission to provide necessary

treatment of emergency care: I hereby give my permission to the medical personnel selected by the camp director to order X-rays, routine

tests, treatments; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for

me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to

secure and administer treatment, including hospitalization, for the person named above. This completed form maybe photocopied for trips out

of camp.

Signature of parent or guardian____________________________________________________________Date___________________________

I do not wish to give the camp permission to give emergency care if I cannot be reached.

Signature of parent or guardian__________________________________________________Date_____________________________________

Revised 7/3/12

Summer Wrestling 2012 Camps Application Form Page 2