Medical Waiver Form Camper's Name* First Last Date of Birth* Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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 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* 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* CommentsThis field is for validation purposes and should be left unchanged.