2024 Hornet Football Prospect Camp Medical Information Form
Please fill out this form with all the required information. Your child will not be able to participate without completion of this form.
Camper's Name *
Camper's Email *
Camper's Cell Phone  *
Home Address *
City *
State *
Zip Code *
Name of Primary Guardian *
Guardian Cell Phone Number: *
Guardian Work Phone Number: *
Guardian E-Mail  *
If Primary Guardian Is Not Available, please list a secondary contact: *
Secondary Contact Phone Number: *
Prescription Medicines Currently Taking (Write N/A if none): *
Non-prescription Medicines Currently Taking (Write N/A if none): *
I give my child permission to self-administer their own prescription medication *
I give my child permission to self-administer their nonprescription medication.   *
My child is aware that he/she may NOT share any medication with other campers. *
Drug Sensitivities/Allergies (Write N/A if none): *
 Epi-pen: Does your child require an Epi-pen to treat an allergy *
Does your child have asthma? *
Does your child use an inhaler and carry it with them? *
Date of last Tetanus vaccination? *
MM
/
DD
/
YYYY
Does your child have any injuries or conditions that presently exist that would limit him/her from camp activities, Yes or No?  If, YES please describe. *
Has your child had any sports or orthopedic (muscle, joint, etc.) injury within the past year, Yes or No?  If YES, please describe. *
Has your child been diagnosed with any other significant chronic illness (diabetes, heart, epilepsy, etc..) Yes or No? If YES, please describe.  *
Insurance Company *
Policy # *
Policyholder's Name (Guardian) *
I affirm that the above statements are true and that no known medical conditions have been purposefully omitted from this form. *
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