Camper's Last Name: Insurance
Company:
Camper's First Name:Policy
Holder Name:
Street: Policy #
City/State:
Zip code:
Phone : ()-
Emergency Contact #1:
Phone (H) ()-(W):
()-
Emergency Contact #2:
Phone (H) ()-(W):
()-
Parent/Guardian E-Mail Address
Medical History (please check all illnesses or conditions that the camper has had)
Allergies
Drug Reactions
Immunizations (indicate dates)
Asthma
Antibiotics ( which type)
Tetanus Toxoid Measles
Hay Fever
Aspirin
Polio
Mumps
Insect Stings
Penicillin
Tuberculin Test
Rubella
Eczema
Sulpha
Other
Other
Medications presently taking:
Past illness or recent injuries: Conditions currently under treatment:
Activity restrictions:
I acknowledge that our child is in good health and can participate in this camp. I agree that in the case of an accident involving my child while attending this camp with full awareness that field hockey is an activity that may invoke risk of serious injury, I release and waive the Stick to Stick Field Hockey Camps; P.J. Soteriades, coaching staff and Denison University from any and all liability for any injuries or illnesses incurred while at camp. In the event of an injury or illness while attending camp I consent to emergency medical or surgical treatment and hospitalization if necessary. I understand in the event that my child becomes sick or injured while at camp that camp personnel will attempt to contact the listed emergency contact person. I will be financially responsible for any and all medical attention needed during camp or resulting from and injury at camp. Stick to Stick Field Hockey Camp, its director and/or staff reserves the right to dismiss anyone from camp who has acted inappropriately and or broken camp rules with out refund. I understand that Stick to Stick Field Hockey Camp retains the right to use for publicity and advertising purposes photographs of players taken at camp.
Stick to Stick Field Hockey has my permission to photograph ,
my child for future event-related materials. Parent/Guardian Signature Date