AUTHORIZATION FOR MEDICAL TREATMENT OF MINORS

Camper Name__________________________        Gender ___M ___F            Date of birth _________

Address, City & State___________________________________         Home Phone_________________

Parent/Guardian Name:_________________________________       Work Phone_________________

Insurance Company_____________________________________     Policy/ID No._______________________

Name of Policy Holder__________________________________        Group No._________________________

Note: A copy of your insurance card must be returned with this form.

Please list two additional contacts in case of emergency (other than parents)

Name, Phone, Relationship________________________________________________________

Name, Phone, Relationship________________________________________________________

Medical Authorization

I/We, being the parent(s) or legal guardian(s) of the above named minor, do hereby appoint the staff of the SUNY New Paltz Summer Sports Camps, to act in my/our behalf in authorizing emergency medical, dental, surgical care and hospitalization for the above-named minor during the following period of Summer Sports Camp (please check appropriate camp):

_____ Baseball                   _____ Basketball                _____ Field Hockey

_____ Soccer                      _____ Girls Tennis             _____ Girls Volleyball

_____ Hawks Sports Camp

_________________________      _________          _________________________      __________

Signature of Parent/Guardian           Date                       Signature of Witness                           Date

PARTICIPANT MEDICAL INFORMATION

Immunization Information:

Please provide a copy of your child’s current school immunization records or complete the section below.

Medical Information:

Date of last physical examination___________________________

Name of physician______________________________________ Telephone No._________________

Family History: (Please list all family diseases, i.e. Diabetes, Tuberculosis, Epilepsy) _______________________________________________________________________________________

Personal History                  (Check the following diseases or conditions the child has had)

Severe injuries/operations and dates ___________________________________________________________________________________

___________________________________________________________________________________

Medical problems, drug or food allergies ___________________________________________________________________________________

___________________________________________________________________________________

Medications being taken at present ___________________________________________________________________________________

I certify that the medical information included on this form is correct.

Signature: ____________________________________________ Date: _________________________

Parent and Prescriber’s Authorization for Administration at Camp

Authorization for Administration of Medication

A. To be completed by parent or guardian:

I request that my child _____________________  age _____ receive the medication as prescribed below by our licensed health care prescriber. The medication is to be furnished by me in the properly labeled original container from the pharmacy. I understand that the camp Medical Director or Head Athletic Trainer will administer the medication or an adult will supervise my child taking his/ her own medication.

Signature of parent/guardian __________________________________ Date ____________

Address _______________________________ Telephone Home_________ Work _________

B. To be completed by licensed health care prescriber:

I request that my patient, as listed below, receive the following medication:

Patient name ____________________________     Date of birth ________________

Diagnosis _____________________________________________________________

Name of medication _____________________________________________________

Prescribed dosage, frequency and route of administration ________________________

______________________________________________________________________

Time to be taken during camp hours _________________________________________

Duration of treatment _____________________________________________________

Possible side effects and adverse reactions (if any) ______________________________

_______________________________________________________________________

Other recommendations ___________________________________________________

Name of Licensed Prescriber and Title (please print) ______________________________________

Prescriber’s signature ___________________________________________ _Date ______________

Address and telephone _____________________________________________________________