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 July 25th. 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 _____________
