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Camp Shutout Medical Form and Waiver

Camp Shutout Medical Form and Waiver

Camp Shutout West Michigan Camper Medical Form

  • Medical Information

    Does the camper have or have they ever had any of the following:
  • Rx Information

  • Medication, dosage, indications, physician’s name
    If yes, please explain injury and cause of injury
    If yes, please explain details
    If yes, please explain details
    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 sports
  • Insurance Information

  • Date Format: MM slash DD slash YYYY
    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.
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