Medical Information Form

Medical Information Form

Participant’s Printed Name:______

Indicate prescription medication (s) which is/are taken on a regular basis:

NOTE: Participant should bring an adequate amount of their medication (s) with them.

Name of Medication - ______Dosage - ______

Prescribing Physician & Phone # - ______

Name of Medication - ______Dosage - ______

Prescribing Physician & Phone # - ______

Is there any medical history involving any of the following:

YesNoYesNo

Allergies ______Heart Disease______

Convulsions______Heat Illness______

Diabetes______Past Injuries/Illness______

Disabilities______Past Operations______

Epilepsy/Seizure Disorder______Other______

If you answered yes to any of the above conditions, please explain in detail.

______

Please advise of any special instructions, side effects or emergency procedures:

______

Date of Last Tetanus Booster ______

Participant’s Signature ______Date______

Parent/Guardian Signature______Date______

THIS FORM IS DUE NO LATER THAN 6/23/16

JOHN CARROLL FOOTBALL TEAM CAMPAPPLICATION

**PLEASE COMPLETE ALL INFORMATION**

**PLEASE PRINT**

First Name______Last Name______

Address______

City______State______Zip______

Home Phone # (___)______Cell Phone # (___)______E-mail______

Who will be transporting you to and from camp?______

Birth date____/____/____

High School______

Parent/Guardian First Name______Last Name______

Home Address (If different than campers)______

City______State______Zip______

Home Phone # (___)______Cell Phone # (___)______E-mail______

T-Shirt Size: SML XLXXLXXXL

EMERGENCY CONTACT INFORMATION

#1 Name______Relationship To Camper______

Home Phone # (___)______Cell Phone # (___)______E-mail______

#2 Name______Relationship To Camper______

Home Phone # (___)______Cell Phone # (___)______E-mail______

CAMPCOSTS:

$155.00 per camper

Make Checks Payable To: Twinsburg Athletic Boosters

RETURN APPLICATION, MEDICAL INFORMATION FORM, PARENTAL CONSENT RELEASE FORM AND PHYSICAL COPY WITH CHECK TO:

CoachBell

THIS FORM AND PAYMENT ARE DUE NO LATER THAN 6/23/16

PARENTAL CONSENT RELEASE OF LIABILITY AGREEMENT

As the parent or guardian, I certify that (PRINT CAMPER’S NAME)______has my permission to participate in the John Carroll Football Team Camp. I/We due herby delegate to John Carroll University and the John Carroll Football Team Camp, their employees, clinicians, trainers, nurses, or agents the authority to seek, obtain, and approve any medical care and treatment including, but not limited to, X-Ray examination, and anesthetic, medical, dental or surgical diagnosis, or treatment and medical care which is deemed advisable by, and is, to be rendered under the general supervision of any physician or surgeon, for the above named minor which, in their judgment, is necessary for the health and well-being of said minor during his/her participation in the John Carroll Football Team Camp.

I/We assign payment to those medical vendors for all services that these same medical vendors may render. It is understood that this authorization is given in advance of any specific diagnosis, or treatment or medical care being required as is to serve as specific consent to any and all such diagnosis, treatment or hospital care which may be deemed advisable. I/We understand that I/We are responsible for any cost incurred that are not covered by insurance and we agree to hold John Carroll University and the John Carroll Football Team Camp, their employees or agents harmless for any liability arising out of any good faith actions taken in and obtaining medical treatment for the above-named minor.

In consideration of the participant in the John Carroll Football Team Camp, the parent/guardian herby releases and holds harmless John Carroll University and the John Carroll Football Team Camp and their employees from any and all liability occurring during the above person’s participation. In particular the person’s parent/guardian acknowledges that he/she and such person will not hold John Carroll University or the John Carroll Football Team Camp liable for any expenses, property damages, personal injuries and/or death sustained by such child while participating in the John Carroll Football Team Camp. Furthermore, the parent/guardian acknowledges that he/she has been, prior to the commencement of the John Carroll Football Team Camp, aware of and understands the risk involved in such activity, and is prepared to assume, on behalf of such child and himself/herself all of such risk as his/her and the child’s sole responsibility. It is said understood that said child will be subject to the rules and regulations of JohnCarrollUniversity and the John Carroll Football Team Camp. I understand that any person who repeatedly disobeys John Carroll Football Camp policies or procedures, will be immediately expelled from the John Carroll Football Team Camp.

The terms and conditions of this Agreement shall be legally binding upon the undersigned parent/guardian and such child and his/her respective estate, representatives and assigns.

Parent/Guardian Signature______Date______

Child/Participant Signature______Date______

ANY COST NOT COVERED BY THE PARTICIPANT’S HEALTH INSURANCE IS THE SOLE RESPONSIBILITY OF THE PARENT OR GUARDIAN. Every camper must be covered by medical insurance. You must complete the following form. If you do not have private health insurance you may not participate in the John Carroll Football Teem Camp.

Policy Holder Name______

Policy Holder Phone #______

Insurance Company______

Insurance Company Phone #______

Policy #______

Group #______

Name of primary care physician______

Phone #______

THIS FORM IS DUE NO LATER THAN 6/23/16

JOHN CARROLL FOOTBALL

TEAM CAMP

SUMMER – 2016

Dear Camper,

Attached are the Application, Medical Information and the Parental Consent Forms for the John Carroll Football Team Camp.

Dates: July7th, July 8th and July9th

Arrival 9:00 AM, July7th –TBA

Depart 5:00 PM, July9th

Cost: $155.00

Make check payable to Twinsburg High School Football.

The Camp Provides:

1. Room – 2 campers per room – supervised by camp staff

2. Meals – Lunch and Dinner on 7/7 - Breakfast, Lunch and Dinner on 7/8 – Breakfast and Lunch on 7/9

3. Training facilities

4. Certified Athletic Trainer

5. Weight Room

6. Meeting Rooms with video viewing capabilities

8. CampT-shirt

9. Practice equipment – sleds, bags, ropes, cones, chutes

Camper Should Bring:

1. Pillows, sheets, blankets, toiletries

2. Fans if it is hot. The rooms are not air conditioned.

3. Enough clothes for every workout.

4. Cleats – appropriate for long artificial turf.

- our players wear screw in or molded bottom cleats

5. Running shoes

6. Some extra money for pizza and or Gatorade.

- pizza will be ordered every evening

- Gatorade available throughout the day

Forms:

1. Application

2. Medical Information

3. Parental Consent

4. A copy of a physical obtained no longer then one year ago.

*All forms, the copy of the physical and $155.00 are to be turned into Coach Bell

Questions: Call Brian Cochran, John Carroll Football Assistant Coach @ 216 397 1677

NO LATER THAN 6/23/16