Paul Hogan Basketball Camps

Annual Health Screening Form

*This form is to be completed by the parent/guardian before participation in the Specialty, Rip City or Point Guard Basketball Camp under the direction of Coach Paul Hogan by the registered camper. Any special needs for a child should be documented in writing (typed) for our records. Any medication needs should be documented for our staff and trainer to assist with the handling of such needs. Please print answers to all the questions. Please meet with our trainer during the registration time on day one of camp.

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