Academy Health Examination Form

Academy Health Examination Form 2005/2006 (page 1); ______Individual Training – Enter Start Date:______________________________________; ______O/N & Day-Okaroh’s Elite Soccer Academy July 8-12; ______O/N & Day-Okaroh’s Ultimate Soccer Academy Session 1 - 2006 - July 30-Aug 4; ______O/N & Day-Okaroh’s Ultimate Soccer Academy Session 2 - 2006 – Aug 6-11; This section is to be filled in by the parents.; Name__________________________________D.O.B_________Sex________Age__________; Mother/Guardian_____________________________________Phone____________________; Home Address________________________________________________________________; Father/Guardian______________________________________Phone____________________; Address_____________________________________________________________________; Insurance name_______________________________________________________________; Subscriber______________________________________Number_______________________; Physician’s Name (child’s)____________________________Number_______________________; If not available in emergency, please notify:; 1. Name__________________________________________Phone______________________; Address_____________________________________________________________________; 2. Name_________________________________________ Phone______________________; Address____________________________________________________________________; PARENT’S AUTHORIZATION; If my child were to become injured or develop an illness, I authorize the medical staff hired by Francis Okaroh’s Ultimate Soccer Academy to evaluate, treat and/or transport my child to the nearest Hospital/Medical Facility and/or a local physician if required. In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. It is understood that Francis Okaroh’s Ultimate Soccer Academy and the New Hampton School, or anyone associated with Francis Okaroh’s Ultimate Soccer Academy is not responsible for accidents resulting in medical, dental or other expenses. Parents will be notified if the above situation were to occur.; MEDICATION AUTHORIZATION; I do_____do not_____ give permission to the medical staff hired by the Francis Okaroh’s Ultimate Soccer Academy to administer appropriate over the counter medication such as Tylenol, Advil, Pepto-Bismol, etc. to my child while he/she is attending camp.; PRESCRIPTION MEDICATION; Please specify any mediation that you will be sending with your child. Please send all medications in their appropriate prescription bottles and send only the exact amount that will be required during your child’s stay.; _____________________________________________________________________________________________________________; ______________________________________________________________________________________________________________; _____________________________________________________________________________________________________________; ______________________________________________________________________________________________________________; ____________________________________________________________________________________________________________; Signature(Required)_________________________________Date________________; I attest that the information on the front and back of this medical form is true to the best of my knowledge and that I have answered every question, leaving no questions blank. Including the two pages of this Camp Health Examination Form and submission of current medical and shot records.; Academy Health Examination Form 2005/2006 (page 2); A medical examination form, including a certificate of immunization and a health history, filled out by your child’s licensed physician must accompany this form. This examination must have been performed within 24 months prior to camp. Please make sure the form contains the following information and is signed by your child’s doctor. Vague phrases such as “immunizations are up to date” or “given in school” will not be accepted. Your form will be sent back to you and your child will not be allowed to attend camp, if your medical form is not complete.; MMR – At least two doses are required.; OPV/IVP (Polio) – At least three doses are required.; DTaP/DTP/DT/Td (Diptheria, Tetanus, and Pertussis) – At least four doses are required.; Td (Tetanus) – A booster dose is required if more than ten years have elapsed since the last dose.; Hepatitis B – All children born on or after January 1, 1992 are required to have three doses.; Please answer the following questions to the best of your ability. If your child does not have or has not had any of the following conditions, please put “N/A” in that space. Do NOT skip any questions or leave any questions blank, otherwise your form will be sent back to you and your child will not be allowed to attend camp.; Allergies: Please specify type and medications taken ________________________________________________________________________________________________________; ________________________________________________________________________________________________________; Operations or Serious Injuries(dates): __________________________________________________________________________________________________________
: __________________________________________________________________________________________________________; Chronic or Recurring Illness (asthma included): ___________________________________________________________________________________________________________; _________________________________________________________________________________________________________; Please note any other health complaints or impairments which may affect your child’s activities while attending camp.; ___________________________________________________________________________________________________________; __________________________________________________________________________________________________________; Are there any specific activities to be restricted? ___________________________________________________________________________________________________________; ___________________________________________________________________________________________________________; Special Diet: ____________________________________________________________________________________________________________; ____________________________________________________________________________________________________________; IMPORTANT: Please notify the camp director if this child is exposed to any communicable disease three weeks prior to camp.