Fillable Printable 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.