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Carthage College Soccer Camp

Health History and Examination

The information on this form is not part of the camper or staff acceptance processes, but is gathered to assist us in identifying appropriate care. This form is to be filled in by parents/guardians of minors or by adults themselves. 

By completing this form, you hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for me/or my child. In the event you cannot be reached in an emergency, you hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the person named below. This completed form may be photocopied for trips out of camp.

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If different from above
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(i.e. allergies, reaction to latex gloves, asthma, medication...)
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(Camper enter name here)