The Track and Field Camp Application medical Treatment Authorization by nmr41826

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									The Track and Field Camp Application                                           medical Treatment Authorization Form
REgisTER AT www.spoRTCAmps.msu.Edu
pLEAsE pRiNT iNFoRmATioN BELow oR ENRoLL oNLiNE                                ______________________________________ DOB___/____/____
                                                                               Participant’s Name
Name: _________________________________________________                                                     Track and Field
                                                                               What Sport: ______________________________________________

Address: ________________________________________________                                                                July 12-16
                                                                               Date of Camp: ____________________________________________

City: __________________________ State: ______ Zip: __________
                                                                               Participants are automatically enrolled in MSU’s accident insurance plan.
Parent or Guardian: ________________________________________                   Eligible covered expenses will be paid only if they are in excess of other valid
                                                                               and collectible insurance.
Daytime Telephone: (_________) ______________________________
                                                                               1. List any medical conditions that camp personnel should be aware of
Evening Telephone: (_________) ______________________________
                                                                               (use additional pages if necessary): ______________________________
E-mail: ________________________________________________                       _______________________________________________________

Grade in September: ___________________ Age: _____________                     2. List any medications currently taking: __________________________
                                                                               _______________________________________________________
Sex: ______ Date of Birth: _____________ Ht: ________ Wt: ________
                                                                               3. List any allergies: ________________________________________
Roommate preference: ______________________________________                    _______________________________________________________

________________________                 ________________________
Suitemate preference                     Suitemate preference                  in case of emergency please contact:

(A SUITE IS TWO ROOMS WITH CONNECTING BATH)                                    _______________________________________________________
                                                                               Name
Position: ________________________________________                             __________________________ ____________________________
                                                                               Daytime Telephone           Evening Telephone
Shirt Size:       qS     qM       qL     q XL                                  _______________________________________________________
                                                                               Name of Medical Insurance         Company Telephone
please enroll me in the following Track and Field camp:
                                                                               _______________________________________________________
Camp Date                    Resident                   Commuter               Insurance Policy Numbers

                                                                               ____________________________________________, as parent or
JuLY 12-16                   q $355.00                  q $290.00              legal guardian of the participant named above, authorizes MSU to seek
                                                                               medical and/or surgical treatment which is reasonably necessary to care
                                                                               for the participant. I further authorize the medical facility that treats the
                              U.S. FUNDS ONLY.                                 participant to release all information needed to complete insurance claims.
                        Please make checks payable to                          I acknowledge my responsibility to pay all costs associated with the partici-
                         miCHigAN sTATE uNiVERsiTY                             pant’s medical care and authorize all insurance payments, if any, to be made
                                                                               directly to the medical facility.
                Check one: q CHECK q MASTERCARD q VISA
                                                                               _______________________________                   ____________________
                                                                               Signature (Parent or Guardian)                     Date
Card Number

3 digit security code                                              Exp. Date
                                                                                   Send Application and Medical Treatment Form with payment in full to:
Signature
                                                                                                        miCHigAN sTATE uNiVERsiTY
Amount of Check/Charge enclosed                                                                              sports Camp office
                                                                                                          402 Jenison Field House
                                                                                                        East Lansing, mi 48824-1025
                                                                                                            Fax: 1-517-355-6891

								
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