PLAYER ______________________________________________________________________________

                                LAST NAME                                                                                      FIRST NAME

 

 

PERMISSION TO PARTICIPATE

 

My child, named above, has my permission to participate in the Francis Cornejo Volleyball Camp (The Camp). My child is in good health and able to participate in all normal volleyball tournament and training activities.

 

Note: While your child is in the care of a coach, an emergency illness or accident may occur which requires immediate medical or dental attention. Your authorized consent, as the child’s parent or guardian, in advance of such treatment serves to protect you, the Camp, the volleyball coach, the doctor, and yourself by assuring that prompt emergency treatment can be administered. This form enables you to provide this consent as well as to offer information helpful in the treatment of your child.

 

CONSENT TO TREATMENT OF A MINOR WITH

INSURANCE CARD INFORMATION

 

The undersigned, parent(s) or guardian of the child named above a minor hereby authorize the coach, or such substitute as he or she may designate as agent for the undersigned, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of any physician or surgeon licensed under the laws of Maryland, and to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to said minor by a dentist licensed under the laws of Maryland, whether such diagnosis or treatment is rendered at the office of said physician or dentist, in the hospital or otherwise.

 

This authorization is given prior to any diagnosis or treatment known to be required in order to enable said coach or agents to act effectively in an emergency situation where I cannot be contacted. Should said coach or agents exercise their authorized consent hereunder upon the advice of a licensed physician and surgeon or dentist, I knowingly and voluntarily exonerate and release said coach or agents of the Francis Cornejo Volleyball Camp from liability for this action.

 

I understand that all reasonable measures will be taken to safeguard the health and safety of my child and that I will be notified as soon as possible in case of an emergency. I am the parent and /or guardian, will be responsible for any medical or hospital bills needed by my child in case of any emergency treatment.

 

This authorization shall remain effective from (date) ____________ through (date) ____________

 

Dated               ___________________________              __________________________________________

                                                                                      Player’s Signature

Witness ___________________________              __________________________________________

                                                                                      Parent’s / Legal Guardian’s Signature

__________________________________

Two adult Witnesses Required

 

 

Page 2 / reverse side of this Form must also be completed

A Copy of this completed form should be in the possession of the team coach at all times during the Camp.

 

NAME              _________________________________________ BIRTH DATE ______________ AGE _____

 

ADDRESS ____________________________________________              PHONE (     ) _____________

 

CITY _________________________________ STATE _____ ZIP __________

 

LEGAL GUARDIAN ___________________________________              PHONE (     ) _____________ (h)

 

ADDRESS ____________________________________________              PHONE (     ) _____________ (w)

 

CITY _________________________________ STATE _____ ZIP __________

 

If I am unavailable in an emergency, please contact:

 

______________________________________________________              PHONE (     ) _____________

 

COPY OF INSURANCE INFORMATION CARD

INSURANCE COMPANY ________________________________POLICY # _____________________

 

ADDRESS _____________________________________________ GROUP # _____________________

 

CITY __________________________________ STATE ____________________ ZIP _______________

 

MEDICAL HISTORY

MY CHILD, named above:

 

1. Has a history of epilepsy:              YES _____              NO _____

 

2. Has a history of diabetes:              YES _____              NO _____

 

3. Is subject to one of the specified:

sleep walking ___   ear infections ___   sinus ___   indigestion ___   hives ___   hay fever ___

sore throat ___   bed wetting ___   appendicitis ___   asthma ___   eye strain ___

heart trouble ___   poison oak ___   allergic reaction to insect stings / bites ___

list allergies, if any:

___________________________________________________________________

 

4. Write any specific conditions, not covered above, which affect participation or treatment

___________________________________________________________________

5. Circle diseases your child has had:              chicken pox              diphtheria              German measles                               

 

mumps                                scarlet fever              small pox              typhoid                                whooping cough

 

6. Give year of immunization:              Tetanus __________              Polio __________

 

7. Is subject to penicillin or other drug reaction? __________ If so, what drug? __________________

 

8. Is your child under any special medical or dietary regime to be continued on an outing?

______________________________________________________________________________________

 

9. Will they bring any medicine with them?              Yes ___              No ___              Name of drug ________________

 

10. Are there factors which would limit your child’s full participation in activities? _______________

 

If so, please explain ______________________________________________________________________________________

 

______________________________________________________________________________________