Paul Hogan Basketball Camps
Annual Health Screening Form
*This form is to be completed
by the parent/guardian before participation in the Specialty,
NAME______________________________________HT._____ WT.____ BIRTHDATE___/____/______
ADDRESS______________________ CITY/STATE_______________________________ZIP________
DATE OF LAST TETANUS SHOT______________ FAMILY DOCTOR_______________________
*Students are required to have a Tetanus Booster (shot) 10 years after their last DPT/TD/DT by New Hampshire State Law. The law requires that children not properly immunized must be excluded from school. If it has been more than six years, please get a tetanus booster administered by a physician.
NOTIFY IN CASE OF EMERGENCY _____________________________________Phone #_______
1. In the last year, have you had any problems with your head, back, arms or legs? No_____ If yes, what are the problems?_____________________________________________________________________.
2. Have you had an operation or serious illness within the past year? No____ If yes, what?________
__________________________________________________________________________________.
Have you ever been told to give up sports because of a health problem? No ______ If yes, what? __________________________________________________________________________________.
3. MEDICATIONS
Currently on any medications? No___ If yes, please list.
*__________________________________________________________________________.
Allergies/Bee Sting? No____If yes, do you need any medications? Please list.
*__________________________________________________________________________.
Do you use an inhaler for respiratory problems? No____If yes, do you need an inhaler during sports?
*__________________________________________________________________________.
4. Please write down any other information you feel would be pertinent?
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
I HEREBY AGREE THAT THE ABOVE STATEMENTS OF MEDICAL HISTORY ARE ACCURATE AND I GIVE MY CONSENT FOR THIS STUDENT TO PARTICIPATE IN ALL CAMP ACTIVITIES.
PARENT/GUARDIAN
SIGNATURE____________________________DATE__________________
HOME
PHONE_____________ EMERGENCY PHONE_____________
*Please bring this in
completed at the time of registration on the first day of camp.
CAMP/CAMPS ATTENDING:
_____RIP CITY _____PT
GUARD ______SPECIALTY