THE GOALIE ACADEMY, INC.
CAMPER MEDICAL INFORMATION
Physical Examination has to be done within the preceding 24 months
Name: _______________________________________________ Sex: ________ Birthdate: ___________________
Address: _____________________________________________ Current Age: ___________
Date of Last Physical Examination: ________________________ Hgt. _________ Wght. ____________
(Please have the remainder of the form completed by a physician)
REQUIRED IMMUNIZATION
(To be completed by healthcare provider)
1. Measles, Mumps, & Rubella. Two (2) Immunizations for measles and one (1) each for mumps and rubella are required. The earliest that the first immunization can be given is 12 months of age.
1st Immunization Month, Day, & Year Received Measles (Rubeola)___/___/____ Mumps___/____/____ Rubella___/___/____
2nd Immunization Month, Day, & Year Received MMR ___/___/____ OR Measles (Rubeola)___/___/____
OR physician diagnosed disease: Measles (Rubeola)___/___/____ Mumps___/____/____ Rubella___/___/____
OR documented positive titer Measles (Rubeola)___/___/____ Mumps___/____/____ Rubella___/___/____
2. Tetanus/Diphtheria (booster must be given within last 10 years) Date Received ___/___/____
MEDICAL CARE
The individual is under the care of a physician for the following condition(s): ______________________________________
____________________________________________________________________________________________________
Medications: _________________________________________________________________________________________
Current Treatment: ____________________________________________________________________________________
Explanation of any reported loss of consciousness, convulsion, or concussion: _____________________________________
____________________________________________________________________________________________________
Does the individual have epilepsy? _______ Diabetes? ________ Asthma? _________ Other? ________________________
Recommendations and/or restrictions while at camp: _______________________________________________________
_____________________________________________________________________________________________________
List any and all allergies: ________________________________________________________________________________
List any and all treatment to be continued at camp: ____________________________________________________________
PARTICIPATION IN ATHLETICS
I have performed a physical examination on this individual on ___/___/____ and he/she is medically cleared to participate in athletics.
YES __________ NO _____________
Signature (physician) ______________________________________________________________ Date ________________
Name (Please print) ____________________________________________________________________________________
Insurance/Waiver Information
Release of Liability/Acknowledgment of Risk
Upon entering events sponsored by The Goalie Academy, Inc., I/we agree to abide by the rules of The Goalie Academy, Inc. and of USA Hockey as currently published. I/we understand and appreciate that participation and observation of the sport constitutes a risk to me/us of serious injury, including permanent paralysis or death. I/we voluntarily and knowingly recognize, accept, and assume this risk and release The Goalie Academy, Inc., its affiliates, their sponsors, event organizers, officials and all personnel from any liability therefore.
READ BEFORE SIGNING.
__________________________________
Parent/Guardian Signature
__________________________________
Date Signed
Medical Release
In the event my child is injured during absence of a parent or legal guardian, I give permission for the person in charge to seek medical attention.
I understand that neither The Goalie Academy, Inc. nor anyone associated with the rink(s) at which they hold The Goalie Academy, Inc. events will assume responsibility for accidents and medical or dental expenses incurred as a result of participation in this program. The applicant is in good health and is able to participate in the physical activity of a vigorous program. In the event of injury or illness while at The Goalie Academy, Inc. camp, I hereby consent and authorize the administration of all treatments and tests that may be considered or necessary in the judgment of the accredited trainers, emergency room physician, or any other clinical physicians.
______________________________________
Player Signature
______________________________________
Parent/Guardian Signature
______________________________________
Date
______________________________________
Emergency Phone Number
_______________________________________________________
Major Medical Insurance Name & Policy Number
Please note that proof of insurance must be provided before goalies will be permitted to participate in any The Goalie Academy, Inc. activity.
THE GOALIE ACADEMY, INC.
PHOTO/VIDEO RELEASE FORM
Photographs and video footage will be taken over the course of The Goalie Academy, Inc. camps.
I understand that my image may be included in photography or video taken for the purposes of publicly promoting, advertising or selling The Goalie Academy, Inc. camps. Photography may appear in print materials, onTthe Goalie Academy, Inc. camp web sites or in informational and instructional videos and on CD-ROMs, DVDs and any other form presently known or future technological advancement.
Photography may also be used for public relations and informational purposes that are requested by the media.
(Check One)
_____ My signature acknowledges the above and authorizes The Goalie Academy, Inc. camps to use photography and video containing my image in its communications media.
_____ I do not authorize The Goalie Academy, Inc. camps to use photography and video containing my image.
Please print name: ______________________________________________
(Parent’s name if under 18 years of age)
Signature: ______________________________________________
(Parent’s signature if under 18 years of age)
Date: ______________________________________________