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SUBMIT MEDICAL INFO

SUBMIT MEDICAL INFO

Medical History

Let's keep you safe

Medical History

Please fill out the medical form and insurance information prior to attending Camp Shutout. This will greatly improve our efficiency on registration day.

Goalkeeper Info
Goalkeeper Name*
First Last
Goalkeeper Date of Birth*
MM slash DD slash YYYY
Medical History
***For each medical issue checked below , please provide specific information in the comments section.***
Does the goalkeeper have or has ever had:
- Asthma
- Allergies
- Broken or Fractured Bone(s)
- Chicken Pox
- Diabetes
- Dizziness/Vertigo
- Epilepsy
- EpiPen (If your goalkeeper requires an EpiPen, they must bring their own.)
- Fainting
- Headaches/Migraines
- Head or Spinal Injury
- Heart Murmurs
- Heat Exhaustion/Heat Cramps
- Heat Stroke
- Irregular Heartbeat
- Muscle Injuries
- Neurological Disorders
- Nose Bleeds
- Other
Please describe any other medical condition your goalkeeper has/have experienced:
Please list the type of inhaler used to control asthma:
Please list all allergies. Be sure to include food allergies, medicine allergies, seasonal, etc.
Additional comments or other medical information:
Medications that your goalkeeper takes regularly:
Does your goalkeeper need assistance with their medication? (Reminders, distribution etc)
- Yes
- No
Consent*
The above information reflects the current medical history for the goalkeeper attending Camp Shutout. I certify that the above information is true to the best of my knowledge.
Concussion History
Number of concussions sustained*
(If your goalkeeper has never had a concussion, please enter 0 and then skip down to the Insurance section)
Date of last concussion:
MM slash DD slash YYYY
Date of medical clearance from last concussion:
MM slash DD slash YYYY
Did they lose consciousness?
- Yes
- No
Explain the injury that caused the concussion:
Insurance, Waiver and Terms
Insurance Policy Holder Name*
First Last
Insurance Company*
Policy Number*
Group Number*
Terms*
I have reviewed and agreed to the cancellation policy.
Camp Shutout 2023 Cancellation Policy
Signature*
I, the undersigned, agree to the terms above.
Email
This field is for validation purposes and should be left unchanged.

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About
- History of Camp Shutout
- Our Crew
Camp Shutout Info
Ask Stan

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Cancellation Policy

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