Bigstuff Info

Topics: Medicine, Insurance, Residency Pages: 2 (439 words) Published: May 30, 2013
Big Stuf Camp 2013 REGISTRATION/MEDICAL RELEASE FORM & MEDICAL/SURGICAL WAIVER Name Address Parent / Guardian Name(s) Parent email (print neatly) Address Home Phone _______________________ Cell Phone Family Physician’s Name Name of Primary Insurance Policy Are all shots & vaccinations up to date? City State Work Phone Phone Policy Number If not which ones are missing? Zip Sex ____ Grade________ Age _______ Birthday City _________________ State ________ Zip

Please List All Physical Limitations (asthma, diabetes, migraine headaches, etc.)

Has Student Had: Appendix removed Chicken Pox Fainting Spells Asthma Heart Trouble Convulsions Diabetes

Medication Authorization: ______ ______ ______ ______ ______ ______ ______ Is student taking any medication that must be given during the trip?__________________ If yes, Complete the following: Please administer to (name) _______________ the following medication(s): Name of Medication: ____________________ Dosage Amount: _______________________ Number of Times a Day: _________________ Name of Medication: ____________________ Dosage Amount: _______________________ Number of Times a Day: _________________

Allergies to Food or Medicine ______ Specify ___________________ Allergies to Bites or Stings ______ Specify ___________________ Any other Allergies ______ Specify ___________________ Are you taking insulin? ______


To be completed by parents or legal guardian of participants under 18 years of age.

I,__________________________, Parent or legal guardian of __________________________, a minor, hereby acknowledge that said minor is presently under my care, custody and control. I hereby give this minor my permission to go to Panama City Beach, Florida, June 23- June 28, 2013. I further grant my permission for this child to participate in all activities of said event. I have listed any physical limitations or medical problems that may need attention. In the event there arises an emergency, necessitating...
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