Stevenson University
Camp/Clinic Medical Form/Waiver

Camper’s name:______Date and Time Attending:______

To be completed by Parent or Guardian:
Date of last tetanus booster:______

List all known allergies:______
______

List any previous musculo-skeletal injuries, surgeries, or diseases related to the musculo-skeletal system. Include any treatment procedures that may influence camper’s participation:______
______

List any medication camper will be taking during participation:______
______

Please make note of any other medical information or medical conditions that we must be aware of during camper’s participation:______
______

WAIVER
As the parent/guardian of the applicant, I hereby grant permission for her to participate in the above camp or clinic at Stevenson University and represent she is physical able to participate in camp/clinic activities. In consideration of the applicant being allowed to participate in the camp, I thereby release the camp/clinic, the University, its employees, volunteers, officers, and agents from all claims resulting from illness, injuries, or other damage, which may be sustained by the child during their attendance at the camp or clinic. Furthermore, I agree and promise that we will not hold the University or any of the aforementioned parties responsible in this respect. This waiver of liability includes transportation to or from the site of the clinic or camp. In the event of illness or injury, we hereby authorize the staff members of the camp/clinic to obtain assistance from doctors, nurses, or athletic trainers for medical, surgical, or any other appropriate treatment for the above mentioned child. Additionally, I grant permission and consent for the attending physician to provide any medical or surgical treatment which in the physician’s professional opinion is deemed necessary. If medical/surgical care is obtained, I will not hold the camp or Stevenson University, its employees, officers, or agents responsible or liable for the judgment of and/or treatment by the physician. I understand that the camp/clinic director, Stevenson University, and the Department of Athletics cannot assume responsibility for medical, dental, or other health expenses incurred as a result of my child’s participation in their camp/clinic.

Signature of parent/guardian:______Date:______
Parent/guardian’s name (please print):______
Home Phone:______Work Phone:______Cell Phone:______

If parent/guardian cannot be reached in case of emergency please notify:______
Phone number:______Relation to camper:______

Additionally, I hereby grant full permission to all persons associated with this event to use any photographs or video clips involving the applicant for publicity or promotional purposes including publication on, but not limited to, gomustangsports.com, facebook.com, and twitter.com.

Signature of parent/guardian:______Date:______

Parent/Guardian Insurance Carrier:______

Policy Number:______

Please provide proof of insurance coverageto the Camp or Clinic.