medical MEDICAL INFORMATION To provide your child with prompt medical by xuyuzhu

VIEWS: 7 PAGES: 2

									                                                MEDICAL INFORMATION
To provide your child with prompt medical care, we must    I certify that_____________________________has my
have a completed consent form on file.                     permission to participate in the HUSA UNITED SOCCER ACADEMY. I
                                                           further certify that the above player has medical insurance in case
_________________________________________________          of injury or emergency. I hereby grant permission to officials of
Camper’s Name Birthday (M/D/Y)                             the HUSA ACADEMY to act for me according to their best judgment
                                                           in any emergency requiring medical attention. Furthermore, I
_________________________________________________          hereby waive and release HUSA UNITED SOCCER ACADEMY, its
Health Card Number                                         employees, agents, officers and staff for any accident or injury
                                                           sustained while at camp.
_________________________________________________
Allergies                                                  _________________________________________________
                                                           Signature
_________________________________________________
Known Allergies / Medical Conditions                       ACADEMY FEES
                                                           The fee for the duration of the academy is $175.00 for each
_________________________________________________          participant.
Medication Presently Taking
                                                           PAYMENT
_________________________________________________          Complete the application and parental consent forms, and
Date of Last Tetanus Booster                               mail them with a check made payable to HUSA CONSULTING INC.
                                                           No telephone reservations will be accepted. All payments are due
                                                           no later than ________.
Does your child suffer from asthma?___________________
                                                           REFUNDS AND CANCELLATION POLICY

Does your child wear contact lenses?___________________    All campers who cancel, regardless of reason, will be re-
                                                           funded all pre-paid fees, except a $50.00 handling fee,
                                                           provided they cancel 10 days prior to camp. Any cancella-
List any recent injuries in the last 6 month:              tions within 7 days of camp will be assessed a $100.00
                                                           handling fee. No refund will be issued for cancellations
_________________________________________________          made within 24 hours of the start of camp for any reason.

List any medication the child takes on a regular basis:    CHECK IN/CHECK OUT
                                                           Campers will register between 12:00pm and 1:00pm. An all
_________________________________________________          camp meeting will be held at 2:30pm on the first day of
                                                           camp. The final session will be completed by 11:00am on
                                                           the last day of camp. Check out and a final all camp awards
EMERGENCY NUMBERS                                          ceremony will be held at 12:00pm on the final day of camp.
_________________________________________________          TRAINERS
Father’s Name                    Cell Number               A certified trainer will be on site to offer prompt attention
                                                           to minor injuries and ailments.
_________________________________________________
Mother’s Name                     Cell Number              SUPERVISION
                                                           All campers will be supervised by camp staff while participating in
_________________________________________________          HUSA United Soccer Academy.
Name and phone number to call if parents cannot be
reached

								
To top