BasketballCamp
Medical Form
Please complete this medical information form and return with the camp registration form. We do not need a copy of a current physical in order to attend camp, but please note any current injuries or medical conditions.
Camper's Name _______________________________________________
Camp Attending _______________________________________________
Physician�s Name______________________________________________
Physician�s Phone # ___________________________________________
List any chronic illnesses or injuries _______________________________
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Current Medications ___________________________________________
____________________________________________________________
List any recent injuries _________________________________________
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The undersigned, being a parent or legal guardian of the child requesting camp attendance, does hereby affirm the applicant is physically able to perform activities at the Winthrop Lady Eagle Basketball Camp and hereby give permission for such medical procedures as may be necessary to this applicant by the camp staff in the event of sickness or injury. I understand that as a condition of camp attendance, the undersigned, on behalf of all parents or guardians, and on behalf of the applicant, hereby releases Bud Childers and all employees or agents of the camp from any and all liability from injury or illness, mental or physical, suffered by the applicant during or related to the camp, unless caused by willful act or gross negligence by the person against whom the claim is made.
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Parent/Guardian Signature Date
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Insurance Company
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Policy #