3d Lacrosse Overnight Camp Medical Form 2017 25% of survey complete. Question Title * 1. Please select all programs your athlete(s) is attending during the 2017 summer. Adventure Camp Box Field Elite - Northeast Box Field Elite - West College Prep Overnight (Committed Camp) DIII Showcase/Road Trip National Team Camp Overnight Select Team Training Camp - Colorado (boys) Overnight Select Team Training Camp - Colorado (girls) Overnight Select Team Training Camp - New England (boys) Overnight Select Team Training Camp - New England (girls) UCCS Girls Overnight Camp Question Title * 2. Athlete Name (Last Name, First Name) Question Title * 3. Date of Birth (mm/dd/yyyy) Question Title * 4. I hereby release and hold harmless 3d Lacrosse staff, volunteers, and designated coaches, from all liability, and from all actions or claims that I or my child now or hereafter have for damage or injury to me or my child, or to any person or property, resulting from the negligence or other acts of any employees or volunteers in connection with me or my child’s participation. I further agree that this waiver, release and assumption of risks is to be binding on the heirs and assigns of the undersigned. (First Name, Last Name) Question Title * 5. Name of Primary Contact Question Title * 6. Relationship to Athlete Question Title * 7. Primary Contact Number (xxx-xxx-xxxx) Question Title * 8. Alternate Contact Name Question Title * 9. Relationship to Athlete Question Title * 10. Contact number (xxx-xxx-xxxx) Question Title * 11. Authorized persons able to pick up Athlete from programming (for athletes 12 and under, please list FULL NAME) Question Title * 12. Primary Physician and Phone Number (xxx-xxx-xxxx) Question Title * 13. Medical Insurance Company and Phone Number (xxx-xxx-xxxx) Question Title * 14. Name of Primary Insurance Policy Holder Question Title * 15. Policy Number and Group Number Question Title * 16. Allergies (please list all including food allergies - if severe please note) Question Title * 17. Current medications (please list all including ibuprofen or Tylenol) Question Title * 18. Does your child have asthma or exercise induced asthma? Yes No Question Title * 19. If yes, do they have an inhaler? Yes No Question Title * 20. An Athletic Trainer will be on site at all times during this camp. They are able to assist your child to ensure they take the correct dose of medication. Does your child need assistance with any medication? Yes No Question Title * 21. If medication assistance is needed please list the medication, dose, time of day to take, and any additional instructions. Question Title * 22. Any other pertinent medical history including heart or respiratory conditions, diabetes, joint injuries, broken bones and sprains, or chronic pain issues? Question Title * 23. List any restrictions to activities while at camp Question Title * 24. I hereby grant permission to administer, and accept any financial responsibility for any and all medical attention necessary to be administered to my child/ward in the event of any illness or injury while attending the 3d Lacrosse Camp. Any representative of the 3d Lacrosse Staff is designated to act on my behalf until I have been contacted directly. (First Name, Last Name) Question Title * 25. Additional Athlete attending programming? Yes No Next