Eastern Washington University2016 Football Summer Camp Medical Release and Consent for Treatment

This medical release waiver must be completed and submitted at registration. Medical insurance and the information regarding your health care coverage must be completed on this medical consent and waiver. EWU Camp Programs do not provide medical care coverage.

Camp Name: _________________________________________ Camp Date(s): ___________________________________

(Please Print)

Camper Name (First, Middle, & Last): ____________________________________________________________________

Birthday: ______--______--______ Age: ______

Mailing Address: __________________________________________________________________________

City: ___________________________________ State: _____________ Zip: ________________

Parent or Guardian - Emergency Contact: __________________________________ Relation: ______________________

Home Telephone Number: (_______) ________ --___________ Work Telephone Number: (_______) ________ --___________

Cell Telephone Number: (_______) ________ --___________

Alternative Emergency Contact Name: ____________________________________ Relation: ______________________

Alternative Telephone Number: (_______) ________ --___________

Insurance Provider's Name: _____________________________________________________________________________

Policy/Identification Number: __________________________________________________________________________

Subscriber's Name: _____________________________________________________________________________________

Provider's Mailing Address: __________________________________________________________________________

City: ___________________________________ State: _____________ Zip: ________________

Pre-Existing Medical Conditions (Include allergy and medication information)

______________________________________________________________________________________________________

______________________________________________________________________________________________________

A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD IS REQUIRED, PLEASE PLACE COPY IN BOXES PROVIDED BELOW

FRONT COPY OF CARDDO NOT STAPLE!ONLY USE TAPE: TAPE AROUND EDGES, SO COPY LIES FLAT ON PAPERDO NOT ATTACH COPY ON SEPARATE PIECE OF PAPERCOPY OF CARD MUST BE PLACED HERE

BACK COPY OF CARDDO NOT STAPLE!ONLY USE TAPE: TAPE AROUND EDGES, SO COPY LIES FLAT ON PAPERDO NOT ATTACH COPY ON SEPARATE PIECE OF PAPERCOPY OF CARD MUST BE PLACED HERE

I hereby authorize the Camp Director, EWU, its staff or agents to administer emergency medical treatment to my child, for any injury or other medical emergency while attending EWU summer camp. This consent also extends the right to EWU, its staff or agents, to arrange for immediate medical treatment by a licensed physician and/or other trained medical personnel, and for them to provide such emergency medical care as they deem appropriate to preserve life or well-being. I hereby release, hold harmless and indemnify the State of Washington, EWU, its staff or agents for any injury or damage related to administration of emergency medical care as authorized herein.

I know of no medical or physical problems which might affect my child's ability to safely participate in the camp. I will be responsible for any medical or other charges in connection with his attendance at camps held at Eastern Washington University.

Parent/Guardian Signature: ________________________________________________ Date: ________________________________