NIU WRESTLING CAMPS CONSENT TO TREATMENT
LIMITATION AND WAIVER OF LIABILITYIn partial consideration of our child’s acceptance into the Northern Illinois University Wrestling Camps, I/we as parents of
Camper's Name____________________________________________________________
do hereby agree to limit the liability of the Northern Illinois University Wrestling Camps , Northern Illinois University, its employees, agents, officers, staff and physicians, to the coverage of the medical insurance policy covering participants in the Northern Illinois University Wrestling Camps as explained in this brochure, which we have read and understand. I/we further agree to waive all liability of the Northern Illinois University Wrestling Camps, Northern Illinois University, its employees, agents, officers, staff and physicians, for any accident, injury (including death), illness or other mishap which might be-fall the above-named camper while traveling to or from, or during his/her attendance at the Northern Illinois University Wrestling Camps, which is not covered by said medical insurance policy.Further, I/we hereby grant permission to the staff and physicians of Northern Illinois University, and medical or surgical consultant deemed advisable, and any hospital to render to the above-named camper any medical and surgical treatment that they deem necessary. I/we understand that all possible effort will be made to inform me/us in case of such treatment.
PARENT AUTHORIZATION/RELEASE OF INFORMATION
This health history is correct to the best of my knowledge and my son/daughter has my permission to participate in workshop activities with the exception of those noted under physical restrictions.
I authorize Northern Illinois University Health Services to release medical information regarding the above named participant to interested parties including parents and family physician.
______________________________________________________________________________
PARENT OR LEGAL GUARDIAN'S NAME (printed)______________________________________________________________________________
SIGNATURE_(_________)___________________________________________________________________
PHONE: Day_(_________)___________________________________________________________________
PHONE: Cell or Pager_(_________)___________________________________________________________________
PHONE: EmergencyCAMPER’S HEALTH FORM Check all that apply
To be completed and signed by camper’s parents or legal guardians.
| Asthma | Head Injury/Concussions |
| Bleeding Disorders | Heart Disease |
| Convulsions/Seizures | Rheumatic Fever |
| Diabetes |
Allergies To Drugs_____________________________________________________________________
Allergies To Foods_____________________________________________________________________
Last Tetanus Immunization (date)________________________________________________________
Current Medications___________________________________________________________________
Chronic Or Recurring Illnesses___________________________________________________________
Operations/Injuries (including dates)______________________________________________________
__________________________________________________________________________
Physical Restrictions__________________________________________________________________
Physician Name_______________________________________________________________________
Physician Telephone_(_______)__________________________________________________________
Dentist Name_________________________________________________________________________
Dentist Telephone_(_______)____________________________________________________________
Camper's Date of Birth _____/_____/_____
Insurance Information (must be completed in full to participate)
Insured Name_________________________________________________________________________
Insured SSN__________________________________________________________________________
Name of Company_____________________________________________________________________
Address_____________________________________________________________________________
Policy Number________________________________________________________________________
Phone Number_(_______)_______________________________________________________________
(please attach a copy of your insurance card and additional medical information, and a doctor's note authorizing the use of a cast or splint, if applicable, or if recovering from a recent illness or injury.)
