MEDICAL INFORMATION AND PARENTAL CONSENT FORM
All Areas of This Form Must Be Completed and Signed Prior to Camp Participation
Camper’s Name _________________________________Birth Date_______________
Allergies and Medications
Allergic reactions (drugs, food, asthma)_______No________Yes
If yes, list: ___________________________________________________________________
Taking any medication at this time?____No________Yes
If yes, List:____________________________________________________________________
In Case of Emergency
FatherTel ( H) . _______________ ____(W) ____________________(c)__________________
Mother Tel ( H) . _______________ ____(W) ____________________(c)__________________
Other Emergency Contact: Name _________________________________________
Tel ( H) . _______________ ____(W) ____________________(c)_______________________Guardian’s Name______________________________ Relationship ________________
Your Medical Insurance
Company ___________________________________________________
Policy # ________________________________ Name of Policy Holder _____________________
Any instructions regarding your insurance _______________________________________________
_______________________________________________________________________________
Parental Consent and Waiver
I/We, the undersigned hereby certify that I (we) am (are) the parent or legal guardian of the camper. I hereby
give permission for the staff of the Camp, to seek, during the period of the Camp, appropriate medical attention for the camper;and for medical attention to be given: and for the camper to receive medical attention in the event of accident, injury, or illness.
I will be responsible for any and all costs of medical attention and treatment,including all deductables and costs beyond the insurance
coverage on the camper. The camp will not provide secondary medical insurance.
I/We, the undersigned, for ourselves and as guardian(s) of
(Camper’s Name)_______________________________________________________________
understand that soccer is an active, physical sport, and that injuries can take place during play. I/ We also understand there willbe a number of children attending camp, there will be a limited number of coaches and/or counselors, and that our child can not
receive individualized attention andsupervision all of the time. I/We understand that, as with any sport, injuries can occur,
and we hereby acknowledge that our child is physically fit and mentally capable of participating in soccer and camp activities.
I/We, represent that I/We have sought the opinion of our child’s pediatrician,
(Name of Camper’s Physician)__________________________________ and he/she concurs that,
(Camper’s Name)_____________________ is fully capable of safely engaging in these activities.
I/ We also understand that it is my/our responsibility in caring for the camper listed above, to be assured that he/she is fully
capable of engaging in this sport’s activity, and I/ we are confident that he/she is able to engage in such sport.
I/ We, the undersigned, for ourselves, our heirs, executors and administrators, waive, release and forever discharge
Washington University, Chaminade H.S., and the Joe Clarke Soccer Camps, and their respective staff, officers,
agents, employees, representatives, successors and assignees of and from all rights and claims for damages, injury, or loss to person or property which
may be sustained or occur during participation in Camp activities or while at Camp, whether or not damages, injury, or loss is due to negligence.
Signature of Parent or Guardian ___________________________________Date ____________________
Address _____________________________________________________________________________
City/State/Zip Code ____________________________________________ Phone_____________________Please Print and mail with the application and the deposit (residential) or full payment (day camps).