2008 Illinois Sport Camps Medical Info, PhotoMedical Release Form by nrt87341

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									              2009 University of Illinois Summer Sport Camps
        Medical Info, Photo/Medical and Transportation Release Forms

MEDICAL INFORMATION

EMERGENCY INFORMATION
(Please write legibly.)

NAME: _________________________________________________DATE: ______________________

DISABILITY: _______________________________

ADDRESS: _____________________________________________________________________________
               Street                 City                                  State/Zip Code

AGE: _____________      SEX: ___________       BIRTH DATE: __________________


PARENT/GUARDIAN EMERGENCY CONTACTS

NAME: _______________________________________________________________________________
                                                                            Relationship
HOME PHONE: _ (____) ___________________________
WORK PHONE: _ (____) ___________________________

ADDRESS: ____________________________________________________________________________
               Street                 City                                  State/Zip Code


NAME: _______________________________________________________________________________
                                                                            Relationship
HOME PHONE: _ (____) ___________________________
WORK PHONE: _ (____) ___________________________

ADDRESS: ___________________________________________________________________________
               Street                 City                                  State/Zip Code



MUST PROVIDE THE INFORMATION BELOW

Family Doctor's Name________________________________________________________________
Clinic/Hospital______________________________________________________________________

City, State _______________________________________________   Phone (   ) _____________

Health Insurance Provider Name: ____________________________________________________

               Policy Number: _____________________________________________________
HEALTH INFORMATION STATEMENT

Check any information you feel the staff may need to know in order to maximize the safety and the well-being of the
participant. Below the condition statement is space to add additional information about the condition checked.
Please be specific. In case of an emergency, this health information may be the only source of information. This
information is confidential.

[ ]     Neurological Disorders (epilepsy, convulsions, frequent headaches)

[ ]     Lung disease (asthma, persistent cough, tuberculosis)

[ ]     Disease of heart or blood vessels, increased or abnormal blood pressure

[ ]     Pain in chest or shortness of breath (heart murmur, rheumatic fever)

[ ]     Stomach or intestinal trouble (ulcers, gall bladder or liver disorder, jaundice, hernia, colitis,
        constipation, frequent diarrhea)

[ ]     Arthritis, diabetes, kidney or bladder disease, blood in urine, frequent urination

[ ]     Hay fever or allergies
[ ]     Allergy to medicines or foods (including penicillin, tetanus)

[ ]     Impaired sight or hearing, chronic ear infections
[ ]     Recent surgical operations, accidents or injuries within past 2 years (fractures, back problems,
        joints)

[ ]     Any infectious disease

[ ]     Skin disease

[ ]     History of skin problems (decubitus ulcers)
[ ]     Ear, nose, throat, or sinus problems
[ ]     Gum or tooth problems (retainers, braces, dentures)

[ ]     Currently taking medicines (list names, frequency and doses)

[ ]     Medication that needs refrigeration (list names, frequency, and doses)

[ ]     Under on-going care of a physician (NAME and PHONE #) for chronic or recurring problem

[ ]     Are there any medically dictated limitations to physical activity?
        NO [ ] YES [ ]
        Please explain:

[ ]     Have you had?      Scarlet Fever               Measles      German Measles
                           Chicken Pox                 Mumps ______ Other: _____________

[ ]     Date of last TETANUS BOOSTER: ____________________________________

[ ]     Do You Wear Glasses?                  YES [ ] NO [ ]              SOMETIMES [ ]

[ ]     Do You Wear Contact Lenses?           YES [ ] NO [ ]
MEDICAL AND PHOTO RELEASE
I state to you that I am in excellent physical condition. My activity should not be limited or participation hindered
because of any physical ailment. If my physical condition should change between the time of this statement and the
time the camp begins, I will notify you. If any emergency arises involving my physical well-being, I give UIUC
Division of Disability Resources and Educational Serives full permission to protect and assist me as you deem
necessary and I release you from all responsibility for such actions. I respect the camp staff's professional judgment
if they feel my physical condition is serious enough to warrant being released from my duties as a member of the
camp staff.

I realize any sport can cause an individual serious injury. Participation in any sport even as a staff member is an
acceptance of some risk of injury. In order to minimize this risk it is necessary that I be aware of and abide by the
guidelines and safety rules set forth by the camp administration.

I will agree to pay any medical expenses or any other expenses that may be incurred as a result of treatment given
me for camp related injuries. I make these statements as consideration for your allowing me to be a member of the
camp staff and to fully participate as such in the Summer Wheelchair Sports Camp.

As a part of the consideration for participating in the aforementioned event I release, hold harmless, and forever
discharge the University of Illinois at Urbana-Champaign, their board of trustees, employees and agents, from any
and all liability claims, demands, actions and causes of actions whatsoever arising out of or relating to any loss,
property damage, or personal injury, including death, that may be sustained by me to any property belonging to me,
whether caused by the negligence of the University, their employees or agents, or otherwise, while participating in
such activity. Further, I hereby grant full permission to any and all of the foregoing to use any photographs,
videotapes, motion pictures, recordings or any other record of this event. This release and hold harmless agreement
is binding on myself, my heirs, assigns and personal representatives.

SIGNATURE: __________________________________________________ DATE: ________________
                Parent or Guardian if under 18 yrs. of age


Please check the camp(s) you wish to attend:
                                   Elite Camp
                                   Coaches Clinic I
                                   Individual Camp
                                   Coaches Clinic II
                                   Track Camp
TRANSPORTATION INFORMATION FORM
**due no later than 14 days before the first day of camp attending

Please complete and return this form even if you are planning on driving your athlete to camp. This is especially
important to ensure all athletes will arrive at camp with the proper transportation. Sport Camp staff will only provide
transportation from public hubs (i.e.: Willard Airport, Illinois Bus & Train Terminal).

NAME: _______________________________________________________________________
              Last                         First                      Middle

ADDRESS: _________________________________________________________________________
               Street                       City                      State/Zip Code


I will provide my own transportation to and from camp.                                                       Yes         No

I will arrive and depart on public transportation and will need transportation to the Florida Avenue Residence Hall.

                                                                                                             Yes        No

If you answered “no” to providing your own transportation, please continue. If you answered “yes” to providing your own transportation, you
are finished with this form.
----------------------------------------------------------------------------------------------------------------------------- ----

PUBLIC TRANSPORTATION INFORMATION
(Please email itinerary to pcisnero@illinois.edu)

ARRIVAL
What form of transportation will you use?                        Train               Plane              Bus ______

Name of transportation carrier:                       Arrival: (Date)            (Time) _______
If plane, what is your flight number and what city are you departing from? __________&______________

If bus or train, what city are you departing from? ______________________________________________

DEPARTURE
What form of transportation will you use?                        Train               Plane              Bus ______

Name of transportation carrier:                                 Departure: (Date)                      (Time) _______

If plane, what is your flight number and what city are you departing to? __________&______________

If bus or train, what city are you departing to? ______________________________________________


EQUIPMENT INFORMATION:

Will you bring an everyday chair?                   Yes______ No _____
Will you bring a basketball wheelchair?             Yes______ No______
Will you bring a track chair?                       Yes______ No______


Please check the camp(s) you wish to attend:                                                           Coaches Clinic I
                                                                      Individual Camp                  Coaches Clinic II
                                                                      Track Camp

								
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