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If yes, please indicate what condition and what type of medication and
dosage:__________________________________________________________________
________________________________________________________________________
Is the medication in possession of camper? ___yes ___no____
The Peak Performance Hockey Camps does not require a signed medical release
from the camper’s physician.
PARENTAL AUTHORIZATION
The health history listed above is correct as far as I know, and the above named camper has my permission
to engage in all program activities except as noted. If a serious injury or illness develops, medical and or
hospital care will be given. Staff members are not responsible in case of accidental injury or illness. Further,
I understand that in case of medical emergency I will be notified. In the event that I cannot be reached, I
hereby give my permission to the attending physician to hospitalize, secure proper treatment for, and to order
injection, anesthesia, or surgery for the child named above.
THIS FORM MUST BE MAILED BACK! Do Not Fax It - We Need This Original Copy!