Medical History

This form must be completely filled out by a parent/guardian, signed and returned in order for the camper to participate in camp. The camper does not need to have a physical or have a doctor fill out this form unless the parent/guardian feels it is necessary.

Campers Name
Campers Name
First
Last
Please check off the camp they will be attending:
Guardian Name
Guardian Name
First
Last
Guardian Name
Guardian Name
First
Last
Guardian(s) Address
Guardian(s) Address
City
State/Province
Zip/Postal

Emergency Contact

First
Last

Insurance Information (Please do not submit this form without completing this section)

Is Sports Camp participant covered by insurance

Medical History

Does your child, or has your child ever had any of the following conditions? If so, please state date and who cared for you: (if your child presently has this condition please state so.)
Asthma: Exercise Induced
Asthma: Allergy Related
Allergies: Food
Allergies: Skin
Are you presently taking any prescription medications?
Have you ever had this condition?

Participant Disclaimer

I understand that my child will not be allowed to participate without this form being completed and signed prior to camp check-in. I understand that I am responsible for payment of all treatment and referrals. I hereby authorize the University of Southern Maine to release medical information to physicians and others responsible for my child’s care. The University of Southern Maine has my permission to arrange and provide care by staff, athletic trainers and/or local emergency personnel, in the event that my child is injured or sick and I cannot be contacted. I also understand that the camper is subject to immediate dismissal if he/she does not comply with the camp’s rules, or if the camper’s participation is not in the best interest of the camp. Campers are responsible for any damage inflicted to USM property.
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