Registration Medical/Emergency Form

Please fill out this form for each of your campers. Thank you!

Your Name (required*):

Your Email*:

Campers Name*:

Age*:

Date of birth*:

Grade entering*:

Address*:

Town*:

State*:

Zip*:

Parent/Guardian name*:

Home phone:

Cell phone*:

If Parent/Guardian is unavailable, please list an adult familiar with your child that we may call in case of emergency.

Name*

Relation (neighbor/friend)*:

Home phone:

Cell phone*:

Medical Information

Insurance Company*:

Policy #*:

Camper physician*:

Telephone*:

Camper dentist*:

Telephone*:

Does your child have any allergies*?
YesNo

If yes, please explain:

Does your child have any medical conditions that we should be aware of*?
YesNo

If yes, please explain:

Will your child be taking any medication at home – prior to the camp day*?
YesNo

If yes, please explain:

Is your child on any medications that they will bring to camp*?
YesNo

If yes, please explain:

RELEASE STATEMENT

I, the parent/guardian of the above named camper, give permission for my child to receive emergency medical treatment and hospitalization, if necessary. I understand that every attempt will be made to contact me, or the named alternate contact above, before taking this action. By enrolling my child, I ensure that he is physically and mentally able to participate in all of the programs activities. I hereby waive and release Lazer Lax Lacrosse – its directors and staff from any liability for any injury or illness incurred while attending camp. I understand that there is a risk of injury to my child as a result of camp activities, and knowingly and voluntarily assume all risk of such injury. I will be financially responsible for any medical attention needed during camp or resulting from an injury received at camp. My medical insurance shall be the insurance coverage for any medical treatment.

I give permissionI do not give permission

T Shirt Size Youth L, Adult Sm M L XL*