Rather Print & Mail A Check MEDICAL FORM Athletes Information Please complete ONE FORM PER ATHLETE. This form must be entirely completed in order to take part in camp. * Athletes Name First Last * T-Shirt Size (these are gender specific) XS S M L XL Roommate Requests * Address: Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code * Phone: * DOB: * Age: * Gender: Male Female * Years Skiing: Ski Team Club: Emergency Contact Information Father's Name: First Last Father's Cell: Mother's Name: First Last Mother's Cell: Other Emergency Contact: First Last Other Emergency Contact Number: EMERGENCY MEDICAL RELEASE and CONSENT By Checking this box below I/We, understand that competitive nordic skiing; training for competitive nordic skiing; and all the other activities relating to Dublin School programs are dangerous and physically demanding activities and that serious personal injury to the above athlete is possible. I/We acknowledge and accept the inherent dangers of physical injury to participants in these activities, and hereby agree to allow the above athlete to participate in all such activities. I/We hereby release Dublin School and any other employees of the camp and agree to hold all said parties harmless from any and all claims, demands, causes of action, and/or attorney fees arising out of or in any way related to any personal injury or property damage sustained by/to the above athlete while involved, spectating, or being transported to and from Dublin School activities. I/We have read and understand this release and voluntarily, willingly and knowingly have executed this release as evidence of our agreement to all of its terms. I/We the undersigned, as parent(s) and/or legal guardian(s) of the above athlete recognize that medical treatment may become necessary during the above athlete’s travel and participation in the Dublin School programs. In the event of an emergency requiring treatment, surgery or the administration of other medical services, permission is granted by us, who is the parent and/or guardian of the athlete listed on the form, a minor, to Dublin School Coaches and Staff to act on his/her behalf, should attempts to contact the above named person(s) prove to be unsuccessful. I/We hereby empower the coaches and staff of Dublin School to authorize on my/our behalf recommended medical treatment by any doctor, emergency medical technician and/or paramedic that is advisable for the care and treatment of the above named athlete. This authorization is complete in and of itself and is fully operative upon my signature for the duration of the above athlete’s participation in Dublin School athletics. I/We, the undersigned, represent that I/we have sought the opinion of (name of the athlete’s physician/pediatrician), and they concur that athlete list on this form is fully capable of participating in the physical demands of the Dublin School athletics. * Agree To Terms I Agree IMPORTANT MEDICAL HISTORY & INSURANCE INFORMATION * Family Physician’s Name: First Last * Physician’s Phone: Allergies: (food, drugs, other): Current Medications: * Date of recent Tetanus Booster: List any pre-existing conditions (asthma, epilepsy, diabetes, head injuries/concussions, fractures, surgeries, severe sprains/strains, hemophilia) and explain: * Medical Insurance Company: * Policy Holder: * Policy Number: * Policy Phone: * Policy Holder’s Date of Birth: * Copy of the athlete’s insurance card Max file size is 20 MB. Please include a picture of athlete's insurance card with this form. This form must be entirely completed and returned in order to take part in the Camp.