SPECIALTY OR POINT GUARD BASKETBALL CAMP

ANNUAL HEALTH SCREENING FORM

*This form is to be completed by the parent/guardian before participation in the Specialty 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.

NAME_____________________ YEAR OF GRAD. _________HT._____ WT.____ BIRTHDAY_______

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?________

__________________________________________________________________________________.

3. Are you currently on any medication? No_____ If yes, what? _____________________________

__________________________________________________________________________________

4. Have you ever been told to give up sports because of a health problem? No ______ If yes, what______________________________________________________________________________.

5. Do you have any allergies? No______ If yes, what? _______________________________________

____________________________________________________________________________________.

Bee Sting. If yes, Do you need medication? What type? _____________________________________.

6. Do you use an inhaler for respiratory problems? No______ If yes, what? _______________________

____________________________________________________________________________________.

Will you need your inhaler during sports? __________________________________________________.

7. Please write down any other information you feel would be pertinent? No____ If yes, what ______

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

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.

DATE___________ PARENT/GUARDIAN SIGNATURE___________________________________

Home Phone # _________________Work Phone #_______________ Emergency Phone #____________

*Please bring this in completed at the time of registration on the first day of camp.