Shepherd University Sport Camp Medical Release/authorization; Acknowledgment, And Waiver Of Liability Form

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Shepherd University Sport Camp
Medical Release/Authorization; Acknowledgment,
and Waiver of Liability Form
Acknowledgment and Waiver of Liability: As a parent of a camper, by signing this form, I acknowledge and
knowingly assume all risks associated with my son/daughter participating in the camp, and I acknowledge that
injury may even arise from negligence by the participants or others and I assume full responsibility for the
participation of my son or daughter. I hereby release Shepherd University, the Athletic Department, Camp
Director, Coaches, medical staff and other campus personnel from any claims or responsibility for any injuries
suffered at the sport camp on the Shepherd University campus. Since the camp does not provide medical
insurance for campers, it is my responsibility to pay for all off-site medical treatments that may be needed. I have
reviewed the information relating to the camp and I certify that my son or daughter is in good physical condition
and can participate in Shepherd University’s sports camp(s). If this camp includes overnight stays, I acknowledge
that my son/ daughter will not have 1:1 adult supervision and that it is reasonable to have my son/daughter stay
overnight on the campus.
________________________________________
Signed
Medical Information and Release:
I authorize the site director and staff to request medical treatment as necessary to ensure the well being of my son
or daughter.
High School of Camper___________________________________________________
Name of Camper: _______________________________________________________
Name of Parent or Guardian: ______________________________________________
Address: ______________________________________________________________
City, State Zip: _________________________________________________________
Phone Numbers: Home_____________________-- Work _______________________
Mobile ______________________
Known Allergies of Camper: _______________________________________________
List Pre-existing medical conditions as Heart Murmur, Asthma, Diabetes, etc._________
________________________________________________________________ or None
List Medications Currently Being Taken:______________________________________
________________________________________________________________________
Family Physician: _________________________Phone___________________________
Please return to the address below
Coach Jeff Jefferson
Shepherd University Baseball
PO Box 5000
Shepherdstown, WV 25443

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