Camp Shutout West Michigan Camper Medical Form Athlete Name* First Last Date of Birth MM DD YYYY Phone*Emergency Contact* First Last Emergency Contact Phone*Medical InformationDoes the camper have or have they ever had any of the following:Heart MurmurYesNoDetails about Heart MurmurIrregular PulseYesNoDetails about Irregular PulseDizziness/FaintingYesNoDetails about Dizziness/FaintingNose BleedsYesNoDetails about Nose BleedsDiabetesYesNoDetails about DiabetesEpilepsyYesNoDetails about EpilepsyHeadachesYesNoDetails about HeadachesAsthmaYesNoDetails about AsthmaInhalersYesNoDetails about InhalersHeat ExhaustionYesNoDetails about Heat ExhaustionHeat StrokeYesNoDetails about Heat StrokeHeat CrampsYesNoDetails about Heat CrampsFractures/Broken BonesYesNoDetails about Fractures/Broken BonesMuscle InjuriesYesNoDetails about Muscle InjuriesChicken PoxYesNoDetails about Chicken PoxAllergiesYesNoDetails about AllergiesRx InformationIs camper taking any medications?YesNoMedicationsMedication, dosage, indications, physician’s nameHas camper ever sustained a head or spinal injury?YesNoIf yes, please explain injury and cause of injuryDetails about Head or Spinal injuryHas camper ever lost consciousness?YesNoIf yes, please explain detailsDetails about lost of consciousnessDo you have any other medical problems that could interfere with full participation in physical activities? If yes, please explainYesNoIf yes, please explain detailsDetails about any other medical problems that could interfere with full participation in physical activities?Parent or Guardian Signature* Checking the box acknowledges the statement This is to certify that the athlete named above has been examined by a physician within the past year, and was found to be physically able to participate in vigorous physical activity and competitive athletic sportsParent or Guardian Name* First Last Insurance InformationPolicy HolderPolicy Holder Date of Birth Date Format: MM slash DD slash YYYY Relationship to CamperName of Group EmployerInsurance CompanyPolicy #Insurance ID #Group #Parent or Guardian Signature* I have read and signed the form BY CHECKING THE BOX ABOVE, I hereby authorize the directors and medical staff of Camp Shutout and Clark Keeper Training to act for me according to their best judgment in any emergency requiring medical attention. I understand that first aid procedures will be rendered by the training staff, and campers will be transported to a hospital if necessary. I hereby waive and release Camp Shutout, Clark Keeper Training and staff for liabilities relation to injury, illness, or expenses incurred. I know of no mental or physical problems which might affect my child’s ability to safely participate in this camp. I will be responsible for any medical or any other charges in connection with their attendance at camp.Parent or Guardian Signature* First Last Date Signed MM DD YYYY
