Medical Waiver Form - Camp Shutout

Camper's Name*

First Last

Date of Birth*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Emergency Contact

If the parents/guardian cannot be reached, who should be contacted?

Contact Person*

First Last

Relationship*

Emergency Contact Phone*

Medical Information

Does 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 Injuries

Has 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 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:*

RX

Medications (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 Information

Policy Holder*

First Last

Policy Holder DOB*

Relation to Child*

Name of group employer:*

Insurance Company*

Policy #*

Insurance ID #*

Group #*

Policy Holder Signature*

Date

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*

Name

This field is for validation purposes and should be left unchanged.