WOCP - Medical Waiver Form

As the parent/legal guardian of blanks born blank I hereby give my consent and permission for the player named below to be medically and/or surgically treated for injuries and/or illness of any kind or seriousness under the direction of WOCP Officials, until such time as I can be contacted.

Further, I give my consent and permission to the physician and/or hospital and/or other health care provider selected to provide medical or surgical treatment, including, without limitation, dental care, hospitalization, injection, anesthesia, invasive surgery or any other form or kind of medical or surgical care (emergency or otherwise) for the player.

Family Physician

Phone

Name of Parent/Guardian

Address

City / State / Zip Code

Phone

Cell Phone

Person to notify if parent/guardian is unavailable

Phone

Insurance Carrier

Group Number

Signature of ParentGuardian

Does your child require an EpiPen?

If your child requires an EpiPen please provide two non-expired EpiPens

Please provide details about your child's anaphylaxis, including the date and description of the reaction.

Does your child have any dietary restrictions?

If yes please explain

Medicine must be brought to camp in its original packaging.

If any over-the-counter medications are sent to camp with your child, they must be in the original package.

Will your child require any treatments while at camp?

Please explain what treatments must be given to your child including the frequency

Will your child be taking any medications while at camp?

Does your child regularly take any medications that will not be taken at camp?

Explain what medications your child takes regularly and why they are taken.

Has your child experienced, or is currently experiencing, any of the following conditions? Be sure to fully explain any conditions your child is currently experiencing.

Blackouts/Fainting

Asthma/Inhaler

Concussion

Bleeding disorder

Epilepsy

Seizures

Other

Has your child had any operations

Be sure to fully explain any diseases your child currently has

Has your child ever been hospitalized or had a serious injury? Please explain the reason(s) for hospitalization(s) or the serious injury(ies) and the dates they

It is important to mention any signs of illness that camp staff should look out for

Does your child have any restrictions on activity?

Does your child have any restrictions on activity?Type a question

Please explain what activities must be restricted and list any special accommodations that should be made

Will your child require any special assistance while at camp? Please explain what assistance will be required.

MEDICAL WAIVER FORM