Medical Information

Date: ____/____/____

Name: ______________________ DOB:___________

Parent/Guardian:_____________________

Emergency Phone: ______________________

Explain “Yes” Answers: ______________________________________________

_______________________________________________________________________

If I am not present at the 2004 Basketball Camp Activities in which my child is present so as to be consulted in case of necessity, you are authorized on my behalf and at my account to take such measures and arrange for such medical and hospital treatment as you may deem advisable for the health and well-being of the participant.

Date: __________________

Parent/Guardian Signature: ________________________________

Relationship to camper: ___________________________________

Insurance Information
Name of Insurance Provider: ___________________________________

Policy Number: _________________________________________

Name of Policy Holder: _________________________________________

Participants Physician: _______________________________

Phone Number: _______________________

Participants Dentist: __________________________________

Phone Number: _________________________

Date of Last Tetanus Shot: ____________________________

* Tear off this portion, with Medical and Registration information and send
with payment.