Camp Shutout West Michigan Camper Medical Form Athlete Name* First Last Date of Birth Month Day Year Phone*Emergency Contact* First Last Emergency Contact Phone*Medical InformationDoes the camper have or have they ever had any of the following:Heart Murmur Yes No Details about Heart Murmur Irregular Pulse Yes No Details about Irregular Pulse Dizziness/Fainting Yes No Details about Dizziness/Fainting Nose Bleeds Yes No Details about Nose Bleeds Diabetes Yes No Details about Diabetes Epilepsy Yes No Details about Epilepsy Headaches Yes No Details about Headaches Asthma Yes No Details about Asthma Inhalers Yes No Details about Inhalers Heat Exhaustion Yes No Details about Heat Exhaustion Heat Stroke Yes No Details about Heat Stroke Heat Cramps Yes No Details about Heat Cramps Fractures/Broken Bones Yes No Details about Fractures/Broken Bones Muscle Injuries Yes No Details about Muscle Injuries Chicken Pox Yes No Details about Chicken Pox Allergies Yes No Details about Allergies Rx InformationIs camper taking any medications? Yes No MedicationsMedication, dosage, indications, physician’s nameHas camper ever sustained a head or spinal injury? Yes No If yes, please explain injury and cause of injuryDetails about Head or Spinal injury Has camper ever lost consciousness? Yes No If yes, please explain detailsDetails about lost of consciousness Do you have any other medical problems that could interfere with full participation in physical activities? If yes, please explain Yes No If 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 Holder Policy Holder Date of Birth MM slash DD slash YYYY Relationship to Camper Name of Group Employer Insurance Company Policy # 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 Month Day Year
