Download FCA CAMP REGISTRATION / MEDICAL FORM REGISTRATION

FCA CAMP REGISTRATION / MEDICAL FORM
REGISTRATION & MEDICAL HISTORY, TREATMENT PERMISSION AND RELEASE
NOTE: This form is required prior to participation in summer sport camps. Participation will not be
permitted until this form has been completed and signed and is on file with the sports camp.
Name: _____________________________________ Age:_________ Date of Birth:_____________
Address: ____________________________________ City:________ State:________ Zip:________
Camp Location _________________________________________________________
School:___________________________________________
Grade:___________________
Huddle Coach:____________________________________
Email:____________________________________________
Father/Guardian Name: _________________________________________
Address: ____________________________________ City:________ State:________ Zip:________
Phone: (h) ___________________ (w) ____________________ (c) ________________________
Email:_________________________________________________________
Mother/Guardian Name: _________________________________________
Address: ____________________________________ City:________ State:________ Zip:________
Phone: (h) ___________________ (w) ____________________ (c) ________________________
Email:_________________________________________________________
Other/Emergency Contact Person Name: _______________________________________________
Phone: (h) ___________________ (w) ____________________ (c) ________________________
Family Physician: ______________________________________ Phone: _______________________
Insurance Company: ________________ ID#: _________________
Medical History (please use the back of this sheet if necessary): _____________________________
Date of last Tetanus: ______________ Booster: ____________________
Is the participant under the care of a provider for a medical and/or psychological problem?
NO/YES
Is the participant taking medication prescribed by a health care provider? NO YES
Allergies: If yes, please list the allergy and provide additional information if necessary.
Insect bites/stings NO YES ______________________________________________
Medications NO YES ______________________________________________
Food NO YES ______________________________________________
RELEASE OF LIABILITY: I hereby release and discharge, indemnify and hold harmless the and
Fellowship of Christian Athletes and Hartland Christian Camps, and their members, officers,
agents, employees and any other persons or entities acting on the behalf, and the successors and
assigns for any and all of the aforementioned persons and entities, against all claims, demands,
cost and expense, and causes of action whatsoever, either in law or equity, arising out of or in any
way connected with any property loss and / or bodily injury and / or disability, arising from my
child’s participation in the sports camp activities, including overnight stays on camp property if
applicable.
CONSENT FOR TREATMENT: I hereby give my permission to a camp certified athletic trainer
to supervise on-site first aid for minor injuries. In the event of injury such as broken limb, sprain,
contusion, laceration, concussion, etc., or illness requiring medical diagnosis or treatment, I
hereby give my consent for sports camp staff to secure the proper medical care; including
transportation and hospitalization, if necessary. Every attempt will be made to contact the parent
or guardian to inform you of the need for any medical attention beyond minor first aid, if
necessary. NOTE: Overnight stays on campus may be supervised by camp counselors and not
certified athletic trainers.
PHYSICAL EXAMINATION WITHIN ONE YEAR: I certify that within the past 12 months my
child has had a physical examination by a physician and that he/she is physically able to
participate in the sports camp activities.
ASSUMPTION OF FINANCIAL RESPONSBILITY: I hereby acknowledge that I am responsible for
medical charges incurred during sports camp participation. I further understand that the sports
camp carries an excess medical insurance policy for sports injuries to the camper that may result
from camp activities. Camp insurance has limits and exclusions and any secondary charges not
covered under this plan will be my responsibility. This policy may only be utilized after my
primary insurance company has processed the claims and issued an explanation of benefits.
My signature below indicates that I have read and understand these terms:
Print name: ________________________________________________________ Date: ___________
Signature: _________________________________________________________
Relationship to Participnt: __________________________________________________________
PLEASE ATTACH TO THIS FORM A COPY OF THE FRONT AND BACK OF THE CAMPER’S INSURANCE
CARD.
Waiver and Release Form
Camper’s Name: ______________________________________________________________________
Phone #: ________________________________________________________
I understand the Fellowship of Christian Athletes is not responsible for accidents occurring at camp
or during camp transportation of participants to and from camp resulting in medical, dental, or other
expenses including the loss of personal items. The camp participants will be held responsible for all
property damage and may be sent home without a refund for a violation of camp rules. The applicant
must be in good health and be able to participate in the physical activity of a vigorous program. In the
event that I cannot be reached it is permissible for the Fellowship of Christian Athletes to have a
trainer, doctor and/or hospital treat my child for medical reasons. In addition, I grant Fellowship of
Christian Athletes permission to transport the above named child to and from training fields. Also,
the undersigned individual and/or as parent or legal guardian for the above named child
understands that this camp is not owned or operated by any of Fellowship of Christian Athletes sites
including, Hartland Christian Camp and do hereby agree to waive, release and hold harmless the
Fellowship of Christian Athletes and its agents/employees from any and all causes including injury
and property damage.
Parent/Guardian Signature: ______________________________________________________
Date: _____________________________________
Insurance Company: __________________________________
Policy Number: __________________________ Group Number: __________________________
Special Medical Concerns:
______________________________________________________________________________________
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