Welcome to the 3d Lacrosse Overnight Camp Medical Form

* 1. Please select all programs your athlete(s) is attending during the 2018 summer.

* 2. Athlete Name (Last Name, First Name)

* 3. Date of Birth (mm/dd/yyyy)

* 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)

* 5. Name of Primary Contact

* 6. Relationship to Athlete

* 7. Primary Contact Number (xxx-xxx-xxxx)

* 8. Alternate Contact Name

* 9. Relationship to Athlete

* 10. Contact number (xxx-xxx-xxxx)

* 11. Authorized persons able to pick up Athlete from programming (for athletes 12 and under, please list FULL NAME)

* 12. Primary Physician and Phone Number (xxx-xxx-xxxx)

* 13. Medical Insurance Company and Phone Number (xxx-xxx-xxxx)

* 14. Name of Primary Insurance Policy Holder

* 15. Policy Number and Group Number

* 16. Allergies (please list all including food allergies - if severe please note)

* 17. Current medications (please list all including ibuprofen or Tylenol)

* 21. If medication assistance is needed please list the medication, dose, time of day to take, and any additional instructions.

* 22. Any other pertinent medical history including heart or respiratory conditions, diabetes, joint injuries, broken bones and sprains, or chronic pain issues?

* 23. List any restrictions to activities while at camp

* 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)

T