Emergency Contact Form & Medical Release Form

Emergency Contact Form & Medical Release Form

Must be completed/signed by participant/parent/guardian of minor participant BEFORE participating in activity at Moravian University

Date and Name of Event:

First Name of Participant *

Last Name of Participant *

Emergency Contact

Email address *

First name *

Last name *

Address 1 *

Address 2

City *

State *

ZIP Code *

Cell Phone Number *

Secondary Contact *

Secondary Contact Phone *

If Primary and Secondary contacts are unavailable, please notify the following in case of emergency *

Name and Phone Number

Health Insurance

Health Insurance Carrier *

Policy Number *

Plan Number *

Is physician authorization needed? *

Yes No

Name of Family Physician *

Phone *

Health History

*Please provide approximate dates the participant suffered from allergies and other conditions. You must list an answer for each question.

Allergies

Hay Fever *

Bee/Wasp Stings *

Insect Stings *

Penicillin *

Peanut *

Other Food/Drugs *

Other

Asthma *

Diabetes *

Seizures *

Concussion *

Behavioral/Emotional *

Other *

Please list any major past illness (contagious and non-contagious) *

Please list any major operations or serious injuries (include dates) *

Has the camper ever been hospitalized? *

Does the camper have any chronic or recurring illness? *

Is there anything else in the camper's health history that the program staff should know? *

Are there any activities from which the camper should be restricted? *

Are there any specific activities that should be encouraged? *

Does the camper have any special dietary restrictions? If yes, explain: *

Does the camper wear any medical appliances (glasses, contacts, orthodonture)? If yes, explain: *

Will the camper need to take any medication during the program? If yes, explain: *

Please list the specific prescription or over-the-counter medications below, reasons for medication, and daily dosage. If any medications change prior to arriving at the program, please provide an updated list upon arrival. *

List each medication, reason for medication and daily dosage/time taken.

*If at all possible, medication should be administered at home. Medications will be allowed at the camp/program only when failure to take such medicine would jeopardize the health of a child and he/she would not be able to attend the camp/program if the medicine were not made available.

Waiver Statement

I agree that in exchange for and in consideration of the University’s permitting me to participate in this program and all related activities to it including, but not limited to travel, and intending to be legally bound, I hereby assume all the risks associated with the program and agree to release and hold harmless MORAVIAN UNIVERSITY, its successors, assigns, trustees, officers, employees, and coaches from any and all liability, actions, causes of actions, negligence, debt, claims or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to the program.

Additionally, I understand that any previous injury or condition I have may predispose me to an increased risk of re-injury or increased risk of other injuries or conditions. Furthermore, I understand that in the event of any new injury, there may be short term and/or long-term health related risks involved with continued participation in this program even after proper treatment or rehabilitation.

Lastly, I certify that I have no health-related reasons or problems which preclude or should restrict my participation in this program and that I have secured medical insurance as required for attending MORAVIAN UNIVERSITY and /or any additional coverage.

The undersigned, herewith:

A. Recognizes and acknowledges that neither MORAVIAN UNIVERSITY nor any of its departments and/or divisions carries special health and/or hospital insurance other than such medical and hospital services as are normally provided for students by the Student Health Center, that would provide such insurance benefits coverage for me in the event I should sustain an injury while participating in the above stated activity.

B. Agrees if the undersigned is married and/or a minor, the signature of spouse, parent or guardian appearing the space indicated below signifies acceptance of said spouse, parent or guardian that the terms and conditions hereof shall be binding upon them and shall constitute a release by them of any and all claims, demands and causes of action whatsoever which they or any of them might have against MORAVIAN UNIVERSITY, its successors, assigns, trustees, officers, employees, and coaches, as a result of the undersigned’s participate in the above stated activity.

I have been advised that my signature on this Statement involves the voluntary relinquishment of certain legal rights and that my signature indicates my intent to be legally bound by the terms of this agreement. If I have any questions or concerns about this Statement of Informed Risks and Waiver of Certain Rights, I should consult with counsel or an advisor of my own choice prior to signing it.

Statement of Informed Risks

I acknowledge that the particular program in which I desire to participate is not required for graduation. My participation is wholly voluntary. I hereby acknowledge that I am participating in these activities with the full realization that they may involve a significant risk of bodily injury. I understand that the injury may range in severity from minor to long term catastrophic up to and including death, or damage to property of me and others. Such injuries may require me to incur significant medical expenses. I am aware that it is not to delineate specifically each and every individual injury risk, however knowing the material risks and appreciating and reasonably anticipating that injuries and even death are a possibility. I hereby assume all of the risks which could occur as a result of my participation including the cost of medical care and assistance.

I understand and accept the risks involved. *

Please Print Name as signature. Must be signed by Parent/Guardian if participant under the age of 18

In the event of an injury I give permission for my child to be treated by the Moravian University Sports Medicine Staff. *

Please Print Name as signature. Must be signed by Parent/Guardian if participant under the age of 18

Please make certain that you have adequate health and accident insurance, since Moravian University will not be responsible for injuries resulting from your minor child’s participation in physical activities.

* required field

Camps & Clinics

Emergency Contact Form & Medical Release Form