Health Release

Health History and Release Form

This form must be completed in full, including signature of a physician, and mailed in along with the final payment by August 1st.  A copy of a camper’s school physical, including immunization history and doctor’s signature, may be substituted in lieu of the medical history part of the form if the physical was performed within 12 months prior to the camp start date.  You still must complete the bottom half starting with Health insurance information.  Campers will not be allowed to participate without both the parental release and Health History parts completed in full.

Camper’s Name: _________________________ Date of camp: ________

Sex: ______  Age: _______  Height: _______  Weight: ________

Medical History(check if yes)

__ German Measles   __ Mumps           __ Scarlet Fever   __ Diabetes

__ Measles                  __ Chicken Pox   __ Pneumonia        __ Asthma

__ Other: __________________________________________________

Immunization                        Allergy                                   Drug

History                  Mo/Yr       History         Yes  No           Reactions   Yes No

Tetanus Toxoid      ____          Hay Fever     ___  ___          Sulpha           ___  ___

Polio Vaccine           ____          Asthma          ___  ___          Penicillin       ___  ___

Small Pox vaccine  ____          Eczema           ___  ___          Antibotics     ___  ___

Diphtheria               ____          Hives              ___  ___          (type if yes)  _______

Tuberculin Test     ____           Insect Stings ___  ___          Aspirin          ___  ___

Measles                   ____           Other             _______           Other           _______

If the camper will be taking medication at camp, please indicate name of drug and usage:

__________________________________________________________________________

Please identify any medical information we should have regarding past medical history or suggested physical limitations relating directly to the camper’s ability tp participate in the camp’s training and activities:

___________________________________________________________________________

___________________________________________________________________________

I certify the above-mentioned individual is able to particpate fully in the activities at Cross Country University Running Camp (XCU Camp), based on physical examination within 12 months prior to said camp date:

Signature of physician: _______________________________________

Date:  __________________________

Health Insurance Information

Insurance carrier: ________________________________________

Policy # ___________________________________________

Policy Holder Name: _____________________________________________

Group # _________________________________________

Emergency Information: (if parent/guardian can’t be reached)

Emergency Contact name: _____________________________________________

Emergency Contact Phone # ________________________________________

I certify the above-named camper is in good health, adequately trained, and fully able to participate in all activities of Cross Country University Running Camp (hereby known as XCU Camp).  I know of no restrictions, physical impairments, or any other facts, which in any manner limit his/her participation in the XCU Camp program.  I give permission for the named camper to receive emergency/medical or surgical treatment and hospitalization if necessary.  I understand that every attempt will be made to contact me prior to such action.  I will be financially responsible for any and all costs of medical attention for the named camper.  In consideration of this application I, the below signed, intending to be legally bound, hereby, for myself, my heirs, executors and adminsirators, waive and release any and all rights and claims for damages I may have against officials of XCU Camp or Camp Lindenmere for any and all injuries suffered as a result of participation at this camp.

Parent/Guardian Signature _____________________________________

Date _____________

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