Champlain Valley

Volleyball Camp
Health History

Camper Information

Name__________________Age____Date of Birth_______________

Address____________________________________________________

Parent’s Name_______________________________________________

Home Phone________Work Phone_________Cell phone_____________

Emergency Notification

(We will first attempt to notify a parent. Please specify a person in case we
are unable to locate a parent).

Name__________________________Phone_________________________

Insurance Company__________________City of Company_____________

ID/Policy#_________________________Group #_____________________

Subscriber’s Name_____________Relationship to Subscriber____________

Medical Information (This is a confidential form that will be retained by the

Athletic Trainer and will be available to camp staff in case of emergency).

1. Has camper ever had any of the following:

Bleeding disorder____ Heart Condition____ Diabetes____ Asthma___
Epilepsy____ Head Injury____ Other____

2. Any Allergies? Yes____ No____ ( If yes list allergies and medication).

3. Any medical disabilities? Please list______________________________
4. Major illnesses, persistent conditions or medical problems with date of
occurrences:
___________________________________________________________
 5. Has the camper ever been hospitalized? Please list occurrences:
___________________________________________________

6. Fractures or broken bones? Please list_____________________

7. List any medications, including doses or times. If the camper will be taking
medication
during camp times, please notify the trainer and have medicines available to the athletic
training staff. All medicine including non-prescription will be dispenses for the athletic
training medical staff.
8. Does the camper wear glasses or contact lenses Yes____ No____
9. Please list any pertinent medical information that is not included on this form.

Parent/Guardian Authorization

This form reflects an accurate description of the above named camper’s health history.
The camper herein described has permission to engage in all prescribed activities, except
Noted by me. I hereby give permission for routine medical treatment at the Champlain
Valley Physicians Medical Center.

Signature____________________________Date____________________________

Please mail this completed form with your deposit and camp brochure at the address
printed on the camp brochure and below.