Medical Waiver Form Camper's Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Emergency ContactIf the parents/guardian cannot be reached, who should be contacted?Contact Person* First Last Relationship*Emergency Contact Phone*Medical InformationDoes the camper currently have or have they ever had any of the following:Heart Murmurs* Yes No Specific Info About Camper's Heart Murmurs:*Irregular Pulse* Yes No Specific Info About Camper's Irregular Pulse:*Dizziness/Fainting* Yes No Specific Info About Camper's Dizziness/Fainting:*Nose Bleeds* Yes No Specific Info About Camper's Nose Bleeds:*Diabetes* Yes No Type and Medications Needed:*Epilepsy* Yes No Specific Info About Camper's Epilepsy:*Neurological* Yes No Specific Info About Camper's Neurological Problems:*Headaches* Yes No Specific Info About Camper's Headaches:*Asthma* Yes No Specific Info About Camper's Asthma:*Inhalers* Yes No Specific Information and Types of Inhalers Used*Heat Exhaustion* Yes No Specific Info About Camper's Heat Exhaustion:*Heat Stroke* Yes No Specific Info About Camper's Heat Stroke:*Heat Cramps* Yes No Specific Info About Camper's Heat Cramps:*Fractures* Yes No Provide Type and Date of Fracture*Muscle Injuries* Yes No Specific Info About Camper's Muscle Injuries:*Chicken Pox* Yes No Specific Info About Camper's Chicken Pox:*Allergies* Yes No List Allergies:*Head or Spinal InjuriesHas Camper Ever Sustained Head or Spinal Injury?* Yes No Please explain Camper's head/spine injury and cause of injury*Has the Camper Ever Sustained a Concussion?* Yes No Date of Last Concussion* Date Format: MM slash DD slash YYYY Date of Medical Clearance from Last Concussion?*Please explain injury and cause of injury*Has the Camper Been Diagnosed with Multiple Concussions?* Yes No If seen by physician for concussion provide date of release:*Has the Camper Ever Lost Consciousness?* Yes No Please Explain About Time(s) Camper Lost Consciousness:*RXMedications (medication, drugs, indications, physician's name):Does the Camper have any other medical problems that could interfere with full participation in physical activities?* Yes No Please Explain Other Medical Problems:*Signature*Insurance InformationPolicy Holder* First Last Policy Holder DOB* Date Format: MM slash DD slash YYYY Relation to Child*Name of group employer:*Insurance Company*Policy #*Insurance ID #*Group #*Policy Holder Signature*Date Date Format: MM slash DD slash YYYY I hereby authorize the directors and medical staff of Camp Shutout to act for me according to their best judgment in any emergency requiring medical attention. I understand that first aid procedures will be rendered by the training staff, and campers will be transported to a hospital if necessary. I hereby waive and release Camp Shutout and staff for liabilities relation to injury, illness, or expenses incurred. I know of no mental or physical problems which might affect my child’s ability to safely participate in this camp. I will be responsible for any medical or any other charges in connection with their attendance at camp. Parent/Guardian*Parent/Guardian Signature*Date* Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
