United States Field Hockey Association
2000 Super Camp Medical Information
Has or is subject to: Asthma Convulsions Diabetes Heart Trouble
  Fainting Fainting Spells High Blood Pressure Allergy or reactions
Has had: Vaccine: Measles Mumps Rubella Whooping Cough Chicken Pox
  Disease: Measles Mumps Rubella Whooping Cough Chicken Pox
  Immunization
(Year Given)		 Tetanus Diphtheria Polio     
Latest physical exam: (date) Current health problems?  Yes    No
Presently under medical care?  Yes    No Presently taking any medicines?  Yes    No
Please check the following health problems in the past or present and give the year:
Serious illness  Serious injury  Deformity Surgery Stomach/bowels 
Ear/eye  Nose/sinus  Teeth/tonsils  Chest/lungs  Heart murmer 
Skin/glands  Appendicitis  Kidneys  Menstrual problems 
Hernia  Back/limbs  Sleepwalking  Behavioral conditions 
Other 
*Please attach any further explanation of medical conditions to application.

Medical Information

In consideration of and through my involvement in the Super Camp Program, I (or on behalf of my minor child) acknowledge and agree that I risk bodily injury, including paralysis, dismemberment, and death, as well as loss or damage to property; I knowingly and freely assume all such risk; and I (or on behalf of my minor child) hereby release, hold harmless and promise not to sue the United States Field Hockey Association, the USOC and their officers, agents and / or employees, with respect to any and all such injury, paralysis, dismemberment, death and/or loss or damage (except that which is resultant of gross negligence and/or willful or wanton misconduct).

I certify that (or on behalf of my minor child), to the best of my knowledge, I am in good physical condition and have no disease or injury that would impair my performance or result in my being injured during any program participation.

In addition, I (or on behalf of my minor child) do hereby grant permission for duly authorized medical treatment by certified professionals to be administered to me (or my minor child) in the event of injury or illness during my participation in a United States Field Hockey Association program and that all costs are my responsibility.

Participant's Signature: ______________________________________________ Date: __________________

Parent/Guardian Signature: ___________________________________________ Date: __________________

Emergency Contact: _______________________________________________________________________

Telephone: _________________________________ Relationship: __________________________________

Health Insurance (Company Name and Address): __________________________________________________

Policy No. ____________________________ Name on Policy: _____________________________________

Return to US Field Hockey Association, One Olympic Plaza, Colorado Springs, CO 80909

In order to be considered, application must include completed Registration, Medical Information and Medical Authorization forms and tuition payment in full. Applications accepted through U.S. Mail ONLY. NO FAX APPLICATIONS WILL BE ACCEPTED. Applications will be accepted on a first-come, first-serve basis. Upon receiving registration and tuition, each accepted applicant will be sent a Confirmation Letter including directions and other camp information.