Camp/Clinic Registration

Registration

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent's Phone Number *

Camp Requested *

Parent's Email *

School *

Club Team *

Primary Position *

Parent/Guardian *

T-Shirt Size *

Medical Treatment Authorization

List any medical conditions that camp personal should be aware of *

List any medications currently taking *

List any allergies *

In Case of Emergency, Please Contact:

Medical Insurance Policy Number *

First

Last

Phone Number *

Daytime Contact Phone Number *

Medical Insurance Provider *

Medical Insurance Policy Number *

Participant Name *

As parent or legal guardian of the participant named above, authorizes DBSS to seek medical and/or surgical treatment which is reasonably necessary to take care of the participant. I further authorize the medical facility that treats the participant to release all the information needed to complete the insurance claims. I acknowledge my responsibility to pay all costs associated with the participant’s medical care and authorize all insurance payments, if any, to be made directly to the medical facility.

Parent/Guardian Signature *

Submit

REGISTRATION

Registration

Medical Treatment Authorization

In Case of Emergency, Please Contact: