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SIG Camper Health Form

This health form must be completed by a parent/guardian if camper is under 18 years old at the time of the camp. Campers who are 18 or older at the time of the camp MUST complete their own form. The information requested is to assist us in identifying appropriate care and/or mandated by the State of Massachusetts. Any changes to the information on this form must be reported to camp health personnel as soon as possible. Please attach any further information to help us assist your camper.

Camper Information

Please answer this based on the player's age at the time of the camp

Enter your grade for the most recent school year (e.g. Sophomore)

Please enter your age at the time of the camp you are registering for

Camper Contact Info

Enter in this format: 555-555-1234

Enter in this format: 555-555-1234

Parent/Guardian Contact Info

Enter in this format: 555-555-1234

Enter in this format: 555-555-1234

Enter in this format: 555-555-1234

(if different from camper's country)

(if different from camper's country)

(if different from camper's home address)

(if different from camper's city)

(if different from camper's state)

(if different from camper's province)

(if different from camper's ZIP/postal code)

First Emergency Contact Info

Enter in this format: 555-555-1234

Please enter the most appropriate daytime phone number in case we cannot contact the cell phone number (Enter in this format: 555-555-1234)

Second Emergency Contact Info

Enter in this format: 555-555-1234

Please enter the most appropriate daytime phone number in case we cannot contact the cell phone number (Enter in this format: 555-555-1234)

Camper Medical Information

Does the camper have any known allergies to medications, food, or other (e.g. bee stings, pollen, asthma)?

List all known allergies to medication, food, or other (e.g. bee stings, pollen, asthma) and describe reaction and management of reaction

Explain any restrictions or limitations to activities

Does the camper take medications on a regular basis?

Authorization to Administer Medication

(E.g., on empty stomach/with water)

(E.g., on empty stomach/with water)

(E.g., on empty stomach/with water)

Authorization to Administer Medication to a Camper

(Please type name of child)

Please select which medications you are authorizing Stop It Goaltending to administer

105 CMR 430.160(A) Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows the date of filling, the pharmacy name and address, the filling pharmacist’s initials, the serial number of the prescription, the name of the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, the number in the container. All over the counter medications for campers shall be kept in the original containers containing the original label, which shall include the directions for use. 105 CMR 430.160(C) Medication shall only be administered by the health supervisor* or by a licensed health care professional authorized to administer prescription medications. The health care consultant shall acknowledge in writing the list of medications administered at the camp. If the health supervisor is not a licensed health care professional authorized to administer prescription medications, the administration of medications shall be under the professional oversight of the health care consultant. Medication prescribed for campers brought from home shall only be administered if it is from the original container, and there is written permission from the parent/guardian. 105 CMR 430.160(D) When no longer needed, medications shall be returned to a parent of guardian whenever possible. If the medication cannot be returned, it shall be destroyed. *Health Supervisor – A person who is at least 18 years of age, specially trained and certified in at least current American Red Cross First Aid (or its equivalent) and CPR, has been trained in the administration of medications and is under the professional oversight of a licensed health care professional authorized to administer prescription medications.

General Questions
Has/does the participant:
Immunization Information

An official copy of camper’s physical exam (must be dated within two years of start of camp), and a copy of camper’s immunization record certified by a physician or school nurse must be submitted in order for the registration to be completed. You may upload a PDF, Word, JPG, or PNG document by clicking the button below, OR by scanning and emailing it to kristine@stopitgoaltending.com, OR by faxing it to (781) 376-9033.

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Please upload your Physical Exam report or Note of Good Health for a physical that has occured within two years from the start date of the camp. Maximum size 20MB. Acceptable file formats: PDF, DOC, JPG, PNG.

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Please upload the player's latest copy of immunizations. Maximum size 20MB. Acceptable file formats: PDF, DOC, JPG, PNG

Insurance Information
This section must be completed in order to attend (unless for religious reasons, a legal waiver is signed)

This health history is correct and complete as far as I know. I hereby give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering X-rays or routine tests, as well as necessary related transportation. I agree to the release of any records necessary for insurance purposes. I give permission to the physician selected by the camp to secure and administer treatment, including hospitalization.

This section must be completed in order to attend (unless for religious reasons, a legal waiver is signed)

This health history is correct and complete as far as I know, and the person herein described has my permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering X-rays or routine tests, as well as necessary related transportation. I agree to the release of any records necessary for insurance purposes. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above.

Waiver of Liability/Parental Consent

I/we, the undersigned, hereby certify that I/we are the parent or legal guardian of the camper. I/we further certify that the camper is physically capable of participating in the Camp and all related activities. Upon request by the Camp, I/we agree to provide a doctor’s certificate confirming the camper’s fitness to participate in Camp activities. I/we hereby give permission for the staff of Stop It Goaltending, LLC to seek appropriate medical treatment for the camper during the period of the Camp and for the camper to receive medical attention in the event of an accident, injury, disease or illness. I/we acknowledge there are certain risks inherent in the participation of the Camp. In acknowledging these risks and in consideration for the opportunity to participate in the Camp, I/we hereby agree to hold Stop It Goaltending, LLC, its governing board, directors, officers, agents, consultants, employees, independent contractors and volunteers (collectively, the “Released Parties”) harmless against any liability, loss or damage (including reasonable attorneys’ fees) arising from the participation in the Camp, and release and discharge the Released Parties from any and all claims whatsoever in connection with the participation in the Camp including claims for personal injury or property damage suffered in connection with the Camp.

Please type your full name

As the parent or legal guardian, please type your full name

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