Victory Volleyball Camps Medical Information Form

To ensure that athletes are medically able to participate in all volleyball and other camp activities, please complete this form and return it by e-mail before July 1st. This form must be completed by a parent/guardian when athletes are younger then 18 years of age.

Personal information

Camp date: Session:

Camper’s first name: Last name:

Address: City: Postal code:

Home telephone: Parent’s cell number:

Mother’s name: Father’s name: Guardian’s name:

Doctor’s name: Doctor’s phone:

Health card number:

Allergies

Epipen needed: if yes reason:

Animals: Foods: Drugs:

Other:

Medications

Medications (dosage and times):

Please list any medications being discontinued during your camp session:

Other information

Please state any dietary restrictions:

Please list any restriction to camp activities:

Please list any recent operations, illnesses, or injuries:

Please state any physical or emotional concerns:

Terms and conditions

1. To the best of my knowledge my child is in good health and has not been exposed to any infectious diseases in the past four weeks. If he or she should become exposed to any infectious diseases, or if there is any change in health status between now and the beginning of the camp session, I understand that I must notify Victory Volleyball Camps in writing.

2. In case of an emergency and I/we are not available for consultation, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, order injections, anesthesia, or surgery for my child as named above.

3. I have disclosed all pertinent medical information including information regarding prescription medications.

4. I hereby give permission to allow my child’s physician to give Victory Volleyball Camps medical information about my child should it be required during the camp.

I accept the terms above Name: Date:

SEND WRITTEN NOTIFICATION OF CHANGES AS THEY OCCUR

PLEASE UPDATE INFORMATION, AS REQUIRED, BY E-MAIL

PLEASE RETURN THIS FORM TO:

Save a copy on your desktop. Send an email to and attach the medical form.