VIEWS: 0 PAGES: 4 POSTED ON: 3/25/2012
Thank you for registering for the 2011 GameBreaker Lacrosse Camp at University of Washington - Seattle, WA Girls- July 11-14 Boys - June 27-30 & July 18- 21 We’re looking forward to seeing you at camp this summer! We hope that this camp will be an unforgettable and exciting experience for you to improve your skills and work with some of the top coaches and players from across the country! Please read the packet below as this information is extremely important. Feel free to call us with any questions at 800.944.7112 or email us at email@example.com . This packet can be downloaded at www.LaxCamps.com, under “Download Forms”. Check In Health Form General Camp IMPORTANT! Campers will not be admitted June 27/July 11 or July 18, 12-1PM, at the to camp without this form! front desk of McMahon Hall. GameBreaker Lacrosse Health Form Please Note: Dinner will be the first meal. o Please fill out and bring to check in st All campers should arrive dressed and ready on the 1 day of camp. to play! Health & Safety Check Out We want to ensure your child a safe and June 30/July 14 or July 21 at 12 PM at The positive environment during their time at front desk of McMahon Hall. camp. Drugs, alcohol and cigarettes are Parents are encouraged to attend the strictly forbidden, and will result in morning session of games on the last day immediate dismissal from camp without a starting at 9 AM! Check out will occur refund. immediately after the closing ceremony at Key Deposit the dorms. The School requires a key deposit of $75 Extended Day Campers per camper. Please bring a check made out Beyond the first day, you should plan on to “GameBreaker Lacrosse Camps” for $75. arriving dressed and ready to play at 8:30 The check will be returned to the camper at AM and being picked up at 8:30 PM after the end of camp after they turn in their key. the evening session. Lunch & dinner are Payments included. Final Payments are due in our office by th Camp Address May 15 . If you have a balance and would 407 Gerberding Hall like us to charge it to your credit card, Seattle, WA 98195 please call us at 800.944.7112. Camp Phone Number Cancellation Policy GameBreaker Office: 800.944.7112 A camp credit will be issued to any camper who must cancel prior to camp. The credit will be for the amount paid by the camper. It is transferable to another family member and is good through the 2011 season. Packing List Health Form Pajamas GIRLS: Lacrosse Stick, Goggles Blanket/Sleeping Bag BOYS: Stick, Helmet, Pads Pillow Cleats Shower Towel Mouthguard Brush Athletic Socks Toiletries T-Shirts Portable Fan!!! Shorts Alarm Clock Socks Sunscreen Sweatshirt Spending Money ($30 Maximum) Off-Field Clothes Key Deposit Check ($75) Bedding Linens Bathing Suit Spending Money It is not recommended that excessive amounts of cash be brought to camp. Please remind your camper to keep any spending money in a secure place. Directions - 407 Gerberding Hall Seattle, WA 98195 http://depts.washington.edu/uwclub/directions.htm GameBreaker Lacrosse Camp Health Record & Release Form Every camper must have this health record filled out for camp and brought to check in. Camps held in the following states require this form to be completed and signed by a physician before your child can participate at summer camp (CT, MA, NY, RI). PLEASE DO NOT MAIL AHEAD __________________________________________________ Camp Location: _____________________________________ Other Allergies: :____________________________________ Name:_____________________________________________ DOB:_______________ Age:_________ Sex:______ ________ Medication Parent/Guardian:____________________________________ Please indicate Yes or NO for over the counter medications Address:___________________________________________ that may be administered to your child if necessary due to Home Phone:_______________________________________ injury and/or illness, according to the manufacturer’s Cell Phone:_________________________________________ recommendations, by the GameBreaker Lacrosse Camps Work Phone:_______________________________________ Summer Athletic Trainer. Emergency Contact:__________________________________ Ibuprofen: Y/N Robitussin DM: Y/N Address:___________________________________________ Tylenol: Y/N Benadryl: Y/N Home Phone:_______________________________________ Sudafed: Y/N Pepto Bismol: Y/N Antibiotic ointment: Y/N Mylanta: Y/N Health History Hydrocortisone Cream 1%: Y/N Asthma: Y/N Loss of Limb: Y/N Diabetes: Y/N Cancer: Y/N Immunization History (Please List Dates) Orthopedic Problem: Y/N Mono: Y/N Copy of Immunization Record Preferable Heart Problem: Y/N Depression: Y/N DPT:_________ Booster: _________ Head Injury: Y/N Migraine: Y/N Polio OPV (Sabin): _________ Booster: _________ Ear Infection: Y/N Tuberculosis: Y/N Measles/Mumps/Rubella (MMR) #1______ #2_______ Please explain all “yes” answers________________________ Meningitis:_________ See form, Td:_____ __________________________________________________ Tuberculin Test: _________ Results: _________ __________________________________________________ Hepatitis B #1:_________ #2:_________ #3:_________ Other serious illness or injury: _________________________ HIB #1: _________ #2: _________ #3: _________ List all current medications (Prescriptions, “over the counter” Varicella: _________ and herbal)_________________________________________ Restrictions/limitations for camper while at camp?: Y/N __________________________________________________ If yes, please explain: ____________________________ __________________________________________________ ______________________________________________ Health Insurance Parent’s Authorization Provider:___________________________________________ My child has had a recent physical on __________ and may Insurance Provider Phone Number:_____________________ participate in all activities at the GameBreaker Lacrosse Policy/ID Number:___________________________________ Camp. I give my child permission to be treated by emergency Policy Holder’s Name & DOB:__________________________ response personnel. I understand that every attempt will be Mailing address_____________________________________ made to contact me, or the emergency contact, before taking __________________________________________________ this action. I hereby waive and release the GameBreaker Lacrosse Camps, staff, camp management and sponsors from Physician’s Information any liability for any injury or illness incurred while at camp. I Physician’s Name:___________________________________ UNDERTAND THAT THERE IS A RISK OF INJURY TO MY CHILD Physician’s Signature:________________________________ AS A RESULT OF CAMP ACTIVITIES, AND KNOWINGLY AND (Only needed in: MA, CT, NY, RI) VOLUNTARILY ASSUME ALL RISK OF SUCH INJURY. I will be Address:___________________________________________ financially responsible for any medical attention needed __________________________________________________ during camp. Phone:____________________________________________ Parent Signature Date Allergies Aspirin: Y/N Penicillin: Y/N **NOTE** All medication will be checked and kept by the Sulfa: Y/N Bee Stings: Y/N trainer. All prescription medications must be in their original If yes, does your child carry an Epi Pen: Y/N case/box with the legible prescription label; including Food Allergies: Y/N inhalers. The prescriber’s authorization form must If yes, please list:____________________________________ accompany all medication and requires the physician’s signature.