Camper Medical Form

Please fill out the following form
in order to participate fully in our overnight/extended day camp.

Camper First Name

Camper Last Name

Date of Birth

Parent/Guardian Name

Emergency Contact #1

Emergency Contact #2

Camper Allergies

Camper Medications

Physician Name

Physician Phone

Health Insurance Policy

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate

I declare that the info I’ve provided is accurate & complete

I hereby agree to let my child participate in the sporting activities on this camp. I understand that there are certain risks of injury inherent in the practice and play of soccer, as well as in traveling and other related activities incidental to my participation, and am willing to assume these risks. I hereby certify that my child is fully capable of participating in these sports and that he/she is healthy and has no physical or mental disabilities or infirmities that would that would restrict full participation in this activity, except as included in writing with this application. In addition to giving full consent for my child's participation, I do hereby waive, release and hold harmless Maestro Soccer, LLC, its officers, coaches, sponsors, supervisors and representatives for any injury that may be suffered by my child in the normal course of participation in these sports and the activities incidental thereto, whether the result of negligence or any other cause. I grant permission for my child to receive emergency aid.

Signed

Select a date

Thanks for submitting!