Medical Form
 

(Every student-athlete, parent, and coach attending our camp must fill out this form.

  1. Please provide the following contact information:

    Name:
    Address:
    Email:
    City:
    State:
    Zip:
    Date of Birth
    SS#
    Age
    Sex
    Grade in Sept 2012
    Parent Name
    Parent Cell Phone
    Home Phone
    Work Phone

    If not available in an emergency, notify:
    1.  Contact Name
    Contact Phone Cell Phone
    2.  Contact Name
    Contact Phone   Cell Phone

    Health History (Check those that apply below)
    Allergies Heart Murmurs German Measles
    Hay Fever Ear Infection Measles
    Poison Ivy Rheumatic Fever Chicken Pox
    Insect Stings Convulsions Mumps 
    Penicillin Diabetes Asthma
    Other Drugs Behavior Problems Dizzy Spells
    if you checked any of the above boxes please comment on them here:
     
    Current Medication
    Medication Name
    Medication Dosage per Day
    Medication Name
    Medication Dosage per Day
    Last Tetanus Shot:
    Operations or Serious Injuries
    Chronic Illnesses or Injuries
    Please notify the camp if this camper is exposed to any communicable disease during three weeks prior to camp attendance.
    MEDICAL INSURANCE INFO
    Insurance Company
    Policy Number
    Parent or Guardian Signature
    Parents Authorization

    This health history is correct, as far as I know, and the person herein described has permission to engage in all prescribed camp activities.  I give full permission to the camp to medically treat my child.  In the event I cannot be reached in an EMERGENCY, I hereby give permission to the camp medical personnel to administer medication.  I also give permission to the physician selected by the camp director to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child as named above.

    By clicking submit you agree to these terms.


Lycoming College - 700 College Place   Williamsport, PA 17701 -  PH:  570-321-4264 -  Email: crebs@lycoming.edu