Login

Fillable Printable Health and Consent Form Sample

Fillable Printable Health and Consent Form Sample

Health and Consent Form Sample

Health and Consent Form Sample

HEALTH & CONSENT FORM
This medical treatment and billing authorization form must be completed and
signed by the parent to enable the camper to participate.
Camp Attending ________________________ Camp Code ________
Camper Name _______________________ Age ____ Gender ____
Address __________________________________________________
City / State / Zip __________________________________________
EmErgEncy contact InformatIon
Parent / Guardian ___________________ Relationship ____________
Home Phone ____________________ Work Phone _______________
Emergency Contact _________________ Relationship ____________
Home Phone _________________ Work Phone _________________
HEaltH InformatIon
does camper have a history of:
___ Convulsions ___ Heart Defect/Murmur ___ Asthma ___ Chicken Pox
___ Diabetes ___ Bleeding Disorder ___ Surgery
(past 2 years) ___ Mumps
Brief description of items checked ___________________________
_________________________________________________________
Medications: Type, dosage and frequency (list) _________________
_________________________________________________________
Allergies: (medications, foods, stings, other) ___________________
_________________________________________________________
InsurancE InformatIon
eAsteRn iLLinOis uniVeRsitY ReQuiRes that all sports campers carry health
insurance coverage. The parent/guardian’s personal or injury insurance policy will be
utilized as the primary insurance for the treatment of injuries and hospitalization for
illness or injuries incurred during the sports camps. if you do not possess health
coverage, a temporary policy covering sports camps must be purchased
(through your insurance agent) to cover the camper for the duration of the sports
camp. the name of health insurance carrier and policy number must be written
below in order to attend an eiu sports camp.
Insurance Carrier Name _____________________________________
Carrier Address / Phone _____________________________________
Policy / Group Number ______________________________________
AutHORiZAtiOn FOR tReAtment: I do hereby authorize Eastern’s athletic
training staff to provide rst aid, follow-up care and/or referral to Eastern’s Health
Service Staff, local physician or local hospital for emergency care. Furthermore,
I hereby authorize EIU Health Service Staff to provide medical treatment and/or
referral for further evaluation and treatment for the above named person in the event
this should become necessary while attending camp at Eastern Illinois University.
_______________________________________________________
Signature of Parent / Guardian (required for participation) Date
Athletes must come to the Panther Camps physically sound. no
preventative taping will be administered for injuries received prior to camp.
Login to HandyPDF
Tips: Editig or filling the file you need via PC is much more easier!
By logging in, you indicate that you have read and agree our Terms and Privacy Policy.