Team Camp Health Forms – Ultimate Team Camps

Camp Attending

Team Camp Attending *

Boys Basketball Camp (June 16-18 @UWSP)
Pole Vault Camp (June15-18 @UWSP)
Girls Basketball Camp 1 (June 23-25 @UWSP)
Girls Basketball Camp 2 (June 25-27 @UWSP)
Boys and Girls Wrestling Camp (June 28-30 @UWSP)
Girls Volleyball Team Camp (July 16-17 @UWSP)

Campers Information

Campers Name *

First

Last

Campers Date of Birth *

Campers Phone Number

Camp Attending and High School *

Boys Basketball - BBB, Girls Basketball Camp 1 - GBB1, Girls Basketball Camp 2 - GBB2, Wrestling - W, Volleyball - V POLE VAULT - Just indicate POLE VAULT - ALL SCHOOLS

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Phone *

Would you like to add additional emergency contacts? *

Yes
No

Additional Emergency Contact *

First

Last

Additional Emergency Contact Phone *

Medical Information

HEALTH & GENERAL HISTORY: If the camper should be restricted from any activity please note:

Please identify any medical condition or medical history that would/may require special attention:

Will the camper be taking any medications during camp? *

Yes
No

Please indicate all medications and dosages: *

Do you give permission for the camper to maintain possession of and self-administer all medications? *

Yes
No

*** IF YOU CHOOSE NO*** If you choose not to consent that your athlete can correctly/safely administer medication - the medication will be collected at the start of camp and returned on the last day. If medication is to be collected please have the medication in a clear zip lock bag with camper's name and required dose clearly labeled on the bottle.

Any know reactions to medications?

Anything additionally regarding medication?

Please list any other common conditions (e.g. asthma), Allergies (e.g. Insects), or know reactions from medications.

Health Insurance Information

Doctors Name

First

Last

Doctors Phone Number

Policy Holder's Name: *

First

Last

Policy Holder's Date of Birth *

Insurance Name: *

Policy Number *

Group Number *

Release of Liability

By checking this box I am certifying I have legal ability to consent for the camper. I agree that all information provided is accurate to the best of your knowledge. I am over the age of 18 and I allow Ultimate Team Camps to act in the best determined interest of my child should there be contact not be possible or available. *

I have legal consent for the listed camper

As the parent (guardian) of the named camper, I give permission to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that every attempt will be made to contact me, or the emergency contact named above, before taking this action. 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 understand that the medical staff cannot provide medications (including over the counter medications). *

I consent

I also agree that my child may be transported by bus and/or camp vehicle to an off-site medical center or for emergency medical treatment. The undersigned further expressly agrees that the attached waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. *

I consent

In consideration of my minor child/ward (“my child”) being allowed to participate in this sport camp program, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that: 1. The risk of serious injury from the sports activities involved in this program is always present due to the nature of the sport (s); and 2. FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my child’s participation; and 3. I willingly agree to comply with the program’s stated and customary terms and conditions for my child’s participation. If, however, I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from participation and bring such to the attention of the nearest official immediately; and 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS the Camp, Ultimate Team Camps, its affiliates, officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for activity (“Releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, OR LOSS OR DAMAGE TO PERSON OR PROPERTY, regarding my child and/or arising from his/her activities, WHETHER ARISING FROM NEGLIGENCE OF THE RELEASEES OR OTHERWISE, except for willful misconduct, or otherwise to the fullest extent of the law. I HAVE READ THIS HEALTH FORM AND RELATED CERTIFICATIONS, THE RELASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND THEIR TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. *

I consent

Signature *

I HAVE READ THE POLICIES AND FULLY UNDERSTAND MY OBLIGATIONS STATED THEREIN AND ALSO THE RIGHTS OF Ultimate Team Camps, AND HERBY AGREE to hold harmless Ultimate Team Camps and an agent of Ultimate Teams Camps.