Medical and Parental Consent Form
All campers enrolled in our basketball summer camps must have a medical form completed by a physician and returned to Hoop Mountain by the start of camp.
Click here for a Printable PDF Version of this Form
Please list camp session
Campers Name
Date of Birth Age
Parent/Guardian Home Phone
Work Phone Cellular
Address City State Zip
Emergency Contact Phone
Name of Family Doctor Phone
Insurance Company Policy No. Group No.
PARENT'S AUTHORIZATION: This health history is correct so far as I know and the
person herein described has permission to engage in all prescribed camp activities except as noted by me and the examining physician. I hereby give my permission to the physician selected by the camp director to order X-rays, routine tests and treatment for
the health of my child in the event I cannot be reached in an emergency.
I hereby give permission to the physician selected by the camp director to hospitalize,
secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. I also understand that we are responsible to have health insurance coverage.
Signature Parent/Guardian Date
The camper and his/her parents agree to abide by the rules and regulations set up by the
Camp for health, safety and welfare of the Camp. The following violations of camp rules
will result in immediate dismissal from the camp without refund of camp fee:
- Leaving campgrounds without permission.
- Willful destruction of camp property.
- Use of drugs and/or alcoholic beverages.
- Fighting and/or continued insubordinate behavior resulting in disrupting
of the camp program.
Camper's Signature Date
MEDICAL EXAMINATION - TO BE FILLED OUT BY LICENSED PHYSICIAN
Campers Name
Height Weight
Blood Pressure Pulse
Check any positive answers:
HEAD
- ___Concussion
- ___Severe or migraine headache
- ___Dizziness
- ___Nosebleeds
SKIN
- ___Severe acne
- ___Boils
- ___Recurring rashes
EYES
- ___Loss of vision
- ___Double vision
- ___Detached retina
- ___Contact lens
- ___Glasses
NECK
- ___Numbness of arms or legs
- ___Stiff neck
- ___Wry neck
TEETH
- ___Bridge work
- ___Dental plates
- ___Orthodontic appliances
THROAT
- ___Frequent sore throat
- ___Tonicities
EARS
- ___Ruptured eardrum
- ___Abscess
- ___Draining ear
- ___Hearing Loss
|
CHEST
- ___Deformity
- ___Pain
- ___Heart murmurs
- ___Shortness of breath
- ___Coughing up blood
ABDOMEN
- ___Cramps or pain
- ___Vomiting
- ___Rupture
- ___Bloody diarrhea
- ___History of bloody urine
- ___Sugar in the urine
MALE
- ___Genitourinary disorders
- ___Removal of kidney
- ___Undescended
- ___Other
FEMALE
- ___Gynecological disorders
- ___Removal of kidney
- ___Ovarian cyst
- ___Menstrual cycle
SPINE
- ___Scoliosis
- ___Operations
- ___Pain
EXTREMITIES
- ___History of varicose veins
- ___Severe flat feet
|
Has He/She ever had: (circle yes or no)
Digestive Condition: Yes No -
Pneumonia: Yes No Diabetes: Yes No -
Rheumatic Fever: Yes No
Kidney Disease: Yes No -
Scarlet Fever: Yes No - High Blood Pressure: Yes No -
TB (PPD): Positive or Negative
List any other conditions no listed above
History of Surgical Operations
Date of last tetanus shot
Athletic injuries previously sustained
Do you require any special equipment to participate?
Doctor's comments
I have examined the person herein described and have reviewed the health
history. It is my opinion that this camper is physically able to engage
in camp activities, except as noted above.
Signature of Examining
Physician Date
Hoop Mountain Georgia
PO BOX 163
Glenn Dale, Md 20769
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