Csu Youth Sport Camps Emergency Contact And Health Form
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1CSU Youth Sport Camps EMERGENCY CONTACT AND HEALTH FORM (required)
Camper’s Name
Birth Date
Address
Home Phone
Mother’s name
Father’s name
Employer
Employer
Work hours
Work hours
Work phone
Work phone
Name of person to be notified in an emergency if parents are not available
Name
Phone
Address
Name(s) of any person(s) – other than parents/guardians – to whom the camper may be released.
1.
3.
2.
4.
Is there someone who should, by court order, NOT be allowed to pick up this child?
Name
Description
Child’s Specific Medical Information: PLEASE PRINT CLEARLY
Allergies
Medications
Frequency
Other
Physician
Phone
Address
Office Hours
Hospital preferred for emergency treatment
Health Insurance Company
Policy #
In case of serious illness or injury and if parent/guardian cannot be reached, will you allow your child to be transported to the
doctor or hospital by an employee of Colorado State University or medical personnel?
Yes____ No_____
I hereby give permission to Colorado State University to secure emergency medical treatment for the above named minor child in the
case of the above named school. The parents will accept all expenses of such care.
Signature of parent or guardian
Date
PHOTO RELEASE: I give permission for publication of photos taken of my child during YSC at Colorado State University. I
understand that I will not be paid any royalty or other compensation and I give up my right to have payment if my child’s photo is
published online or in print media. I understand that my child will never be identified by name in any photograph or media.
Signature of parent or guardian
Date
For YOUTH SPORT CAMP FIELD TRIPS: The Camp Director and/or Camp Counselors have my permission to take my child
on scheduled YSC field trips for which advanced notice has been given.
Signature of parent or guardian
Date
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