CLUB KARE MEDICAL, CONCUSSION & INSURANCE FORMS

CLUB KARE MEDICAL FORMS
FORM #1 - CLUB KARE HEALTH FORM
Child's Full Name
First and Last Name
Child's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Address
City
Home Phone
Format: (000) 000-0000.
Cell/Work Phone
Format: (000) 000-0000.
Parent's name
Email
example@example.com
Notify in emergency if parents cannot be reached:
Name
Cell Phone
Format: (000) 000-0000.
Allergies
(if yes, please list)
Date of last Tetanus Vaccination

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Explain any sickness and/or physical limitations
(subject to headaches, asthma, earaches, etc.)
Any limitations in activities?
Eating habits
What has not been covered that we should know about your child to understand and help him/her
Can we give your child Tylenol?
Please select all that apply. (Please give all medication to our staff when you check in on your first day.)

Other
Health Insurance Company
Policy or member number
READ THE FOLLOWING CAREFULLY
1. I will not allow my child to attend Club Kare if, to the best of my knowledge, my child has, or is immediately prior to camp exposed to any communicable diseases.

2. I hereby agree to hold harmless Kare Youth League, its employees, agents and representatives and volunteer assistants for any and all problems, adverse reactions or other medical problem(s) resulting from or due to the medications, medical administration or applications given to my child. By initialing here, I agree I have read this paragraph and waive any and all rights to seek redress from Kare Youth League, its employees, agents, representatives and volunteer assistants.
By entering your initials here you are accepting the terms described in item #2 above
Please enter Your Initials.
3. I will not allow my child to bring any of the following items: radio, ipod, mp3, cell phone, electronic gizmo of any kind, knife, or snacks.

4. In case of sickness or accident, Kare Youth League has my authorization to secure such medical attention as is deemed necessary if unable to communicate with me immediately.
Signature of parent or guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

FORM #2 - PARENT & ATHLETE CONCUSSION INFORMATION SHEET
Here's a copy of the KYL Concussion Information Form. Please be sure to read the pdf below and then fill out your information electronically in the form below this PDF.
STUDENT ATHLETE NAME PRINTED
STUDENT-ATHLETE NAME SIGNED
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PARENT OR GUARDIAN NAME PRINTED
PARENT OR GUARDIAN NAME SIGNED
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

FORM #3 - KARE YOUTH LEAGUE INSURANCE WAIVER
(Print Name of Participant)
(Print Name of Parent/Guardian of Minor Participant)
PARENT OR GUARDIAN NAME SIGNED
(Signature of Participant or Parent/Guardian of Minor Participant) (Date)

**** This Waiver of Liability, Assumption of Risk, and Indemnity Agreement is available on request in both Spanish and English.
Should be Empty:

CLUB KARE MEDICAL FORMS

FORM #1 - CLUB KARE HEALTH FORM

READ THE FOLLOWING CAREFULLY

FORM #2 - PARENT & ATHLETE CONCUSSION INFORMATION SHEET

FORM #3 - KARE YOUTH LEAGUE INSURANCE WAIVER