Youth Program Medical Form 2013-14


Please use this form to provide current medical and emergancy contact information for your child. This form is required for all participants in youth programs at Rock Spot Climbing. We will keep this form on file for one academic year.





Participant Name
Child's Name:

First Name *

Last Name *

Middle Name
Please Select One:    
Male    
Female    


General Information
Date of Birth *
Parent's Contact Info

Parent/Guardian Name *

Relationship *

Address 1 *

Address 2

City *

State *

Zip Code *
Parent's Contact Info

Home: *

Work:

Cell:

Parent's E-mail: *
If the parent/gaurdianlisted above is unavailable, we will notify:
Alternate Emergency Contacts

Name *

Relationship: *

Tel: *
Medical Information
Please note that you are responsible for any medical expenses.
Personal physician:

Physician Name *

Physician Tel: *

Health Insurance Carrier *

Policy/patient # *
Please note any conditions that apply - past or present - to your child's health history. Explain any "Yes" answers below. *
Asthma *
Yes    
No    

Cancer/Leukemia *
Yes    
No    

Convulsions/Seizures/Fainting *
Yes    
No    

Diabetes *
Yes    
No    

Heart Trouble *
Yes    
No    

Hemophilia *
Yes    
No    

High Blood Pressure *
Yes    
No    

Kidney Disease *
Yes    
No    

Allergies (please list below) *
Yes    
No    

Please list any allergies your child has, including allergies to medications.

Please explain any medical conditions (include any other considerations which may affect your child's ability to participate):

Please list any medications your child is currently taking. Please make special note of any medications that need to be taken during camp hours.


Electronic Signature Consent  *
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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