Fillable University of South Alabama Emergency Medical Information (University of South Alabama)

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University of South Alabama Emergency Medical Information (University of South Alabama)

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The University of South Alabama Emergency Medical Information (University of South Alabama) form is 3 pages long and contains:

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File type: PDF

U.S.A. forms for University of South Alabama

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This form must be completed and returned prior to the first day of camp for your child to participate in the camp.
CAMPER NAME:
ADDRESS:
S
treet City State/Zip Code
AGE: SEX: BIRTH DATE:
GRADE: SCHOOL:
P
ARENT/GUARDIAN/OTHER EMERGENCY CONTACTS
NAME:
Relationship
HOME PHONE: ( ) WORK PHONE: ( )
ADDRESS:
S
treet City State/Zip Code
NAME:
Relationship
HOME PHONE: ( ) WORK PHONE: ( )
ADDRESS:
S
treet City State/Zip Code
H
EALTH INFORMATION STATEMENT
Check below any information you feel the staff may need to maximize the safety and the well-being of the camper. To the right of the
condition statement is space for more information relating to the condition checked. Please be specific. In case of emergency, this
health information may be the only source of accurate important information. This information will be kept confidential.
[ ] Mental or emotional health issue
[ ] Seizure disorder
[ ] Lung Disease (asthma, persistent cough, tuberculosis)
[ ] Disease of Heart or Blood Vessels, Increased or Abnormal Blood Pressure
[ ] Pain in Chest or Shortness of Breath (heart murmur, rheumatic fever)
[ ] Stomach or Intestinal Trouble (ulcers, gall bladder or liver disorder, jaundice, hernia, colitis)
[ ] Arthritis, Diabetes, Kidney or Bladder Disease
[ ] Hay Fever or Allergies
(
continued on next page)
University of South Alabama
Emergency Medical Information
Camper Name:
[ ] Impaired Sight or Hearing, Chronic Ear Infections
[ ] Recent Surgical Operations, Accidents or Injuries
[ ] Any Current Infectious Disease
[ ] Any Current Skin Disease
[ ] Allergy to Foods
[
] Do You Wear Glasses? Yes [ ] No [ ] Sometimes [ ]
[
] Do You Wear Contact Lenses? Yes [ ] No [ ]
[ ] Date of last TETANUS BOOSTER
[ ] Significant Orthopedic and/or Neuromuscular Impairment (e.g. loss of limb, spinal cord injury)
[ ] Any other current health related issues?
[
] Up to date on all vaccinations required for school entry? Yes [ ] No [ ]
If not, which are not up to date? __________________________________________________________
P
lease note: For overnight camps, all medications that accompany the camper to camp will be given to a designated
counselor/chaperone. The counselor will dispense the medication in accordance with the directions provided by the parent.
Medication should be in its original container labeled by the pharmacist. Only include enough medication for the time the child will
be attending the camp.
[ ] Allergy to Medicines (including penicillin, tetanus)
[ ] Medication that needs refrigeration
[
] Medicines currently taken by camper, including non-prescription or over-the-counter medications (list names, doses, times)
______________________
[ ] Under on-going care of a Physician (NAME AND PHONE #) for chronic or recurring problem
Family Doctor’s Name: Clinic/Hospital:
City: Phone: ( )
Health Insurance Provider Name Policy Number:
As a parent or guardian, I understand that if a serious illness/injury develops, medical or hospital care will be given. I further
understand that in case of serious illness/injury, I will be notified. However, if I cannot be reached, I give my permission for
emergency treatment, x-ray or surgery, as recommended by an attending physician.
I
also understand if my child becomes ill or injured, my health insurance is primary coverage for those expenses. The University of
South Alabama carries accident insurance that is secondary coverage in the event of an injury.
SIGNED DATE: ____________________________________
(Parent or Guardian)
University of South Alabama
Emergency Medical Information
(continued)
T
o be completed by participant's parent or guardian. The parent or guardian must sign in the presence of one (1) witness.
TO THE UNIVERSITY OF SOUTH ALABAMA:
I understand that my son/daughter, , has the opportunity to participate in
(Name)
USA Student Recreation Center Summer Camps to be held June 7-July 30, 2021 at the University of South Alabama (the
“University”).
I understand that travel to and from the Camp is my responsibility over which the University has no responsibility or
control. Transportation around campus may be provided by the University for certain camps. In the event of inclement
weather, camp staff may transport my child to an enclosed facility either on or off the University campus. I understand
that participation in the Camp is voluntary, and I am aware of, and agree to abide by, the rules and regulations of the
Camp. I further agree to follow all applicable guidelines regarding Covid-19, including, but not limited to, social
distancing and wearing a mask when possible, and to ensure that my child does the same. I understand that while the
University has taken measures to prevent the spread of illness, including, but not limited to Covid-19, the University
cannot make any guarantees about the possibility of contracting illness during the Camp. I acknowledge that I have had the
opportunity to ask questions to my satisfaction regarding this Camp and associated risks prior to signing this Release from
Liability.
In consideration of the University permitting my child the opportunity to participate in this Camp, I, in full recognition
and appreciation of any and all risks, hazards, and dangers inherent in participating in this Camp to which my child may
be exposed, do hereby agree to assume all of the risks and responsibilities surrounding my child's participation in this
Camp, specifically including those risks associated with swimming, transportation, and Covid-19. Further, I do for
myself, my heirs and personal representatives, agree to hold harmless and indemnify, release and forever discharge the
University, its trustees, officers, agents, servants and employees from and against any and all claims, demands and actions
or causes of action on account of or resulting from my child’s participation in this Camp. I further understand that the
University, its trustees, officers, agents, servants and employees assume and accept no liability for personal injury or loss
of life or damage to personal property.
I attest and verify that my child has no physical limitations that would prevent safe participation in this Camp and that my
child is up to date on all immunizations required for school entry.
IN WITNESS WHEREOF, I have caused this Release to be executed on this day of , 2021.
___________________________________________________
Parent/Guardian Signature Witness
Date Date
PHOTOGRAPHIC RELEASE
I authorize the University of South Alabama to photograph, video, and/or audio tape my child for promotional use
of the University of South Alabama.
I do not authorize the University of South Alabama to photograph, video, and/or audio tape my child for
promotional use of the University of South Alabama.
Signature of Parent/Guardian: Date: ______________
USA Recreation Center
Release from Liability for
Camps Sponsored by USA
This form must be completed and signed to complete a camper’s registration and to be allowed to check in and
participate in camp activities
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University of South Alabama Emergency Medical Information (University of South Alabama)

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Completed 26 February 2022

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