Camps / Clinics Emergency Health Information & Parental Authorization printable pdf download

ILLINOIS STATE UNIVERSITY SPORTS MEDICINE

Camps / Clinics Emergency Health Information & Parental Authorization

{please PRINT or type in BLACK ink}

Participant’s Name

________

Date of Birth

_____________________________

Address

Phone #1

Email Address

Mother’s Name

Mother’s Day Phone

_____________

Mother’s Evening Phone

Father’s Name

Father’s Day Phone

_____________

Father’s Evening Phone

Emergency Contact’s Name

Relationship

Phone

Medical Insurance Co.

Policy #

Date of Most Recent Tetanus Immunization?

Medical Conditions (e.g. allergies, diabetes, asthma, epilepsy, disabilities, etc.)

_____________

Current Medications

Parent’s Authorization:

I, the parent / guardian of _______________________________________ , certify that my son / daughter is in good health and fit to

participate in a private sports camp / clinic at Illinois State University.

He / She has undergone a physical by a physician within the past year (date: ___________________), and was given a physician’s

permission to participate in sports related activity.

Signed ____________________________________________ Date _________________ Relationship _________________________

In consideration of the camp / clinic granting the aforementioned individual permission to participate in a private camp / clinic hosted at Illinois State

University, I hereby recognize and acknowledge that there are certain risks of physical injury to participants in the camp / clinic activity, and hereby assume

all risks of camp/clinic activity (including property loss or damage and death) that may result from any activity (including residence hall and/or dining hall

activities) while my son / daughter is enrolled as a participant. As parent / guardian, I do release ,indemnify, defend, and hold harmless the State of Illinois,

the Board of Trustees of Illinois State University, its Athletics Department, the sports camp / clinic in which my son / daughter is enrolled, and Illinois State

University’s officers, employees, agents from any and all liability, including claims and suits at law or in equity, for injury, fatal or otherwise, and property loss

or damage which may result from the participant taking part in sports camp / clinic activities.

I certify that within the past year, the aforementioned participant has had a physical examination by a licensed physician, and that he/she is physically able to

participate in the sports camp / clinic activities.

The camps / clinics program has adopted the following procedures for caring for your son / daughter in the event that he/she becomes sick or injured while

attending the aforementioned camp / clinic: 1) A representative from the camp / clinic will call the home telephone number listed. If there is no answer, 2) A

representative will call the mother’s, father’s, and/or guardian’s day and evening phone numbers as listed. If there is no answer, 3) A representative will call

the emergency contact. 4) If none of the above answer, a representative will call an ambulance, if necessary, to transport your son / daughter to an

appropriate medical facility. 5) Camp / Clinic representatives will continue to call all listed numbers until one is reached. A message may also be left on an

answering machine. 6) Based upon the medical judgment of the attending physician, your son / daughter may be admitted to a local medical facility. By

signing below, you are giving permission for representative(s) of camps / clinic program to follow these procedures if your son/daughter becomes sick or

injured while attending the aforementioned camp/clinic.

In the event of an injury, illness, and/or accident involving my son / daughter, I hereby give my consent for medical treatment and permission to campus /

clinic personnel to supervise on-site first aid, to the appropriate camp / clinic personnel to properly transport my son / daughter to an appropriate medical

facility for care, and to a licensed physician to hospitalize and secure proper treatment (including injections, diagnostic procedures, anesthesia, surgery,

and/or other reasonable and necessary procedures) for my son / daughter. I agree to assume any and all costs related to such treatment. I hereby

authorize my health insurance company to pay benefits for the costs of such treatment. I also authorize the disclosure of medical information to my

insurance company for the purpose of any claim. I understand that each participant must provide his/her own medical insurance in order to participate in the

aforementioned camp / clinic.

I understand that I am responsible for any and all medical and/or other charges related to the aforementioned participant’s attendance and participation in a

private Camp / Clinic at Illinois State University. I also understand that registration is not considered complete until this completed and signed form is on file.

Parent / Guardian Signature

Date

UCF Sports Medicine

07/18/12

Camps / Clinics Emergency Health Information & Parental Authorization

Related Articles

Related forms

Related Categories