Band Camp Health Record | Arkansas Tech University

Camper Name:

Camper Date of Birth:

Gender:

Camp Attending:

Parent or Legal Guardian:

Parent Phone:

Parent Cell Phone:

Name of emergency contact:

Phone for emergency contact:

Please list any medical/health information needed in case of emergency for the safety of your child. Please include medications taken and allergy information:

Camper can be administered Tylenol or ibuprofen if needed:

Is your child covered by health or accident insurance?

Insurance Company:

Policy Number:

IMPORTANT: Our camp health and insurance program is a secondary coverage policy. For more information contact the camp office.

I authorize the Arkansas Tech University Band Camp to obtain licensed physicians of their choice for medical treatment and diagnostic procedures necessary in the event of any illness or accident. In the event of an emergency, I give my permission for any procedure the physicians feel are imperative, understanding that every attempt will be made to notify the parent or legal guardian first. (If religious beliefs are held by your family that would complicate medical procedures, please attach a note to this form.) Also, I hereby authorize the Student Health Services at Arkansas Tech University to provide medication and/or treatment as authorized by the consulting physician and deemed appropriate by the Registered Nurse in charge. The Health and Wellness Center will provide medical assistance only during regular office hours. They will not administer routine medications. (If your child will be taking medication at camp, it should be brought in its original container with the prescription label attached.) Everything is true to the best of my knowledge.

My camper is physically able to participate in camp activities. I understand that group activities, rehearsals, and concerts are photographed and/or digitally recorded and may be used for publicity purposes only. Refer to the camp website for complete camp policies.

I agree to the above policies.

Yes