CEC Medical Form

Medical Form
Select the camp(s) you are attending*

USTA National Campus, Lake Nona (Orlando), FL December 8-9, 2024University of San Diego, San Diego, CA January 2-3, 2025
Camper Name*

First NameLast Name
Camper Email*
(*must use same email you registered with)
Camper Date of Birth*

MonthDayYear
Parent/Guardian E-mail*
(*must use same email you registered with)
Insurance Information
Insurance Company Name*
Policy Number*
Plan Type*
Co-Payment (if applicable)
Emergency Contact

If parent/guardian is not available in an emergency, notify:
Name of Emergency Contact*

First NameLast Name
Contact Number*

Area CodePhone Number
Relationship to participant*
Health History

Please fill out if applicable:
Do you have any food/dietary restrictions? If none, enter "NO"*
Do you have?

Heart ProblemsAsthmaDiabetesOther
Allergies to medication, Operations, serious illness or injuries (provide info & dates):
Are you on any medications? (list all)
Parent/Guardian Authorization

The health history completed is correct and to the best of my knowledge. The person here-in described has permission to engage in all camp activities. In the event that I or persons named above in case of emergency cannot be reached in an emergency, I hereby give my permission to the physician selected by the camp director to hospitalize and/or administer proper medical treatment for my child as named above. I also understand that I will be held responsible for the payment of my child's medical bills.

I AGREE THE ELECTRONIC SIGNATURE BELOW WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian Electronic Signature*

First NameLast Name
Today's Date*

MonthDayYear
Should be Empty:

Medical Form

Insurance Information

Emergency Contact

Health History