Required Medical Forms University Of Texas At Austin

ADVERTISEMENT

Camp you are attending: ________________________________
The University of Texas at Austin
Name of Camp Director: ________________________________
Carlos Hernandez
Department of Intercollegiate Athletics
: ______________ Camp
____________
Camp Director Phone
Fax:
512-232-5119
512-232-1837
REQUIRED ME DICAL FORMS
Camp Mailing Address _________________________________
PO Box 7399, Austin, TX 78713
This form must be completed and returned to the camp director prior to the program start date.
PERSONAL INFORMATION
Camper’s Last Name _____________________________________ First Name________________________ Birthdate___________
M☐ F ☐
Home Address______________________________________________
City_____________________ State______
Zip____________
Home Phone__________________________________________ E-mail Address__________________________________________________
Parent/Guardian 1______________________________________
Daytime Phone_______________
Parent/Guardian 2_______________________________________ Daytime Phone_______________
Health Insurance Carrier_________________________________ Policy Number________________ Plan Number___________________________
PLEASE INCLUDE A PHOTOCOPY OF YOUR INSURANCE CARD
Is physician authorization needed? ☐ Yes ☐ No
Family Physician_______________________
Phone____________
In case of emergency, please notify
If neither parent nor guardian is available in an emergency, please contact:
1. ___________________________________________________________
Phone________________________
2. ___________________________________________________________
Phone________________________
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
This authorizes The University of Texas at Austin physicians, medical personnel and camp sponsors to release information concerning the medical
status, medical condition, injuries, prognosis, diagnosis and related personally identifiable health information of
_________________________________ (participant name) to camp staff. This information includes injuries or illnesses relevant to participation in
the above named camp at The University of Texas at Austin.
SIGNATURE OF PARENT/LEGAL GUARDIAN
DATE
HEALTH HISTORY
Allergies: _______________________________________________________________________________________________________________
Date of most recent tetanus immunization:__________________________________________
Please list any major past illnesses (contagious and non-contagious): ________________________________________________________ ☐ None
Please list any major operations or serious injuries (include dates): _________________________________________________________ ☐ None
Does the youth have any chronic or recurring illness? ☐ No ☐ Yes
Are there any activities from which the youth should be restricted? ☐ No ☐ Yes If YES, explain: _________________________________________
Does the youth have any special dietary restrictions? ☐ No ☐ Yes If YES, explain: ____________________________________________________
Does the youth wear any medical appliances (glasses, contact lenses, orthodonture, etc.)? ☐ No ☐ Yes If YES, explain: _______________________
The University of Texas at Austin honors the privacy of the participants in its programs and complies with the national regulations regarding
health information. Follow this link
to the University Notice of Privacy Practices.
I have received a copy of University Notice of Privacy Practices as required by HIPAA Privacy Rules.
SIGNATURE OF PARENT/LEGAL GUARDIAN
DATE

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 4