HEALTH HISTORY and RELEASE FORM
This form must be completed in full, including signature of a physician, and mailed in along with the final payment.  A copy of a camper's school physical, including the immunization history and a doctor's signature may be substituted in lieu of the top of the form if the physical was performed within 12 months prior to the camp start date.  You still must complete the bottom part starting with Health insurance information.  Campers will not be allowed to participate without both the parental release and Health parts completed in full.

Camper's Name: _____________________________________  Date of camp: _______   

Sex: _______     Age: _______     Height: _______     Weight: _______     

Medical History: (check if yes)
____ German Measles ____ Mumps ____ Scarlet Fever ____ Diabetes
____ Measles ____ Chicken Pox ____ Pneumonia ____ Asthma
____ Other: _________________________________
Immunization History Mo/Yr Allergy History Yes No Drug Reactions Yes No
Tetanus Toxoid _______ Hay Fever ___ ___ Sulpha ___ ___
Polio Vaccine _______ Asthma ___ ___ Penicillin ___ ___
Small Pox Vaccine _______ Eczema ___ ___ Antibiotics (type) ___ ___
Diphtheria _______ Hives ___ ___ _______________________
Tuberculin Test _______ Insect Stings ___ ___ Aspirin ___ ___
Measles _______ Other ___ ___ Other ___ ___
If the camper will be taking medication at camp, please indicate name of drug and usage:

_________________________________________________________________________
Please identify any medical information we should have regarding past medical history or suggested physical limitations relating directly to the camper's ability to participate in the camp's training and activities:
_________________________________________________________________________
_________________________________________________________________________
I certify the above-named individual is able to participate fully in the activities at Cross Country University Running Camp (CCURC), based on physical examination within 12 months prior to said camp date:

 
Signature of physician: _________________________________ Date: ______________
Health Insurance Information
Insurance Carrier: __________________________ Policy Number: ____________________
Policy Holder Name: __________________________ Group Number: ____________________
Emergency Information: (if parent/guardian cannot be reached) 
Emergency Contact Name: ______________________ Emergency Contact Phone #: ______________
I certify the above-named camper is in good health, adequately trained, and fully able to participate in all activities of Cross Country University Running Camp (hereby known as CCURC).  I know of no restrictions, physical impairments, or any other facts, which in any manner limit his/her participation in the CCURC program.  I give permission for the named camper to receive emergency/medical or surgical treatment and hospitalization if necessary.  I understand that every attempt will be made to contact me prior to such action.  I will be financially responsible for any and all costs of medical attention for the named camper.  In consideration of this application I, the below signed, intending to be legally bound, hereby, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against officials of CCURC or Camp Eagle Hill for any and all injuries suffered as a result of participation at this camp.
Parent/Guardian Signature __________________________________ Date: __________