Medical Release Form copy.indd

Cyclone Sports Camps Release Form
Name of Participant (print full legal name) ________________________________________________________________________
Birth Date ______________________________________
Gender (circle one) Male Female
Camp Attending _____________________________________________________________________________________________
Parent/Guardian _____________________________________________________________________________________________
Emergency Phone Number ____________________________________________________________________________________
Release and Medical Authorization
The release and the treatment authorization must be signed by a parent or guardian if student is under 18 years old. Students who are 18 years
old or will become 18 years old before the beginning of the camp/clinic must also sign. In order for students to participate in camp activities,
we must have this signed form returned prior to the camp’s start date. Otherwise, parent or guardian must be contacted prior to release to a
student’s participation.
Physician’s Authorization to Participate
This is to certify that this individual was examined by me on _____________________ (valid if within one year of camp) and that I found
this individual to be physically able to participate in vigorous physical and competitive athletic sports. (School physical form acceptable if
valid within one year of the starting date of camp.)
Allergies/Drug sensitivities___________________________Other medical problems/current medications ___________________
Is an identification band or card carried to alert others to the allergy(ies), medical conditions or medication use? ___Yes ____ No
Physician’s Signature___________________________________________________________________ Date _______________
Address ________________________________________________________________ Office Phone _____________________
Release of Liability to Participate
In consideration of the Cyclone Sports Camps/Clinics of Iowa State University granting the student permission to participate in Cyclone
Sports Camps/Clinics, I hereby assume all risks of his or her personal injury (including death) that may result from any Cyclone Sports Camp/
Clinic activity. As either a Student or Parent/Guardian, I do hereby release the State of Iowa, Board of Regents of the State of Iowa, Iowa State
University, Cyclone Sports Camps/Clinics and their officers, employees, agents from all liability, including claims and suits at law or in equity,
for loss, damage or injury, fatal, or otherwise which may result from the student taking part in Cyclone Sports Camp/Clinics activities.
Parent’s/Guardian’s Signature__________________________________________________________
Date _______________
Student’s Signature__________________________________________________________________
Date _______________
Medical and Surgical Authorization
In addition, I hereby authorize and give my consent to the health authorities of Iowa State University or any licensed health professional to
perform upon or administer any reasonable, necessary surgical or medical treatment. I also give permission to administer whatever anesthetic
may be necessary or advisable during the medical or surgical procedures. This authorization is intended to cover emergency treatment, immunizations, injections, and minor operations and procedures. In the case of psychiatric and/or psychological treatment, parent authorization
for treatment beyond that responsive to the emergency will be requested. I agree to assume all costs related to such treatment. I authorize my
insurance company to pay benefits to Iowa State University Theilen Student Health Center or other hospitals and clinics.
Parent’s/Guardian’s Signature__________________________________________________________
Date _______________
Student’s Signature__________________________________________________________________
Date _______________
Also, I authorize the disclosure of medical information to my insurance company for purpose of claim. I understand that I will be responsible
for any medical or other charges in connection with student’s attendance at this camp. (Each camper must provide his/her own medical insurance.)
Insurance Information (please print)
Name of Insured _______________________________________ Policy Holder ______________________________________
Insurance Company __________________________________________________________________________________________
Insurance Co. Address ________________________________________________________________________________________
Policy No. ___________________________________Does your insurance carrier require prior approval? ______Yes ______ No
This form must be on file for you to participate in any of the Cyclone Sports Camps programs. A copy of a current physical (within one year)
may serve as the physician’s authorization portion of this form. Please contact the camp office for any questions concerning the information
in this document.
Cyclone Track & Field Camp LLC
Contact information: 515-294-7088 Fax 515-294-0125
email @: [email protected]