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Medical Clearance Form 3

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Medical Clearance Form 3
Medical Clearance Form 3
MEDICAL CLEARANCE
I hereby certify the named camper is physically able to participate in Auburn University Sports Camp and
that I know of no physical impairments which would in any manner limit his/her participation in such
program. Physician’s Signature________________________________________Date______________
OR
Provide any physical accompanied with a physician’s signature dated within 12 months
of camp with registration or at check-in (State HS physical, etc)
MEDICAL & INSURANCE INFORMATION
Hospitalization Plan: Claim No._______________________ Company____________________________
City________________________State_________________ Zip Code____________________________
Phone______________________________
*FRONT AND BACK COPY OF INSURANCE CARD SHOULD BE INCLUDED AT TIME OF
CHECK-IN*
Medical History (if pertinent):
_____________________________________________________________________________________
Allergies, present medication, special considerations:
_____________________________________________________________________________________
Parent/Guardian________________________________________________________________________
Address____________________________City__________________State________Zip Code__________
EMERGENCY MEDICAL INFORMATION
______________________________ (___)______________________(___)_________________________
NAME PHONE CELL
______________________________ (___) ______________________(___)________________________
NAME PHONE CELL
Medical Clearance Form 3