Big Man Camp Registration

(*) denotes required information.

A $50.00 per camper fee must be received by June 15, 2014 by the football camp office in order for this registration to be activated.
 
Camper Information:  
* First Name:
* Last Name:
* Address:
* City:
* State:
* Zip:
Email:
* Phone:
 
* Age:
* Entering Grade:
* School:
 
Parent/Guardian Information and Emergency Contact Information:  
* Parent/Guardian:
* Home Phone:
Work Phone:
* Emergency Contact:
* Relationship to Camper:
* Emergency Phone:
 
Medical Consent:  
* Does the camper have any known sensitivity to any food or medication:
Yes No
If yes, please list:
* Does the camper have any physical disability or recurring illness that may affect or impair participation:
Yes No
If yes, please list:
* Does the camper have any ongoing disease:
Yes No
If yes, please list:
* Please provide the date of the latest DPT/Tetanus Toxoid Injection:
 
Insurance Information:  
* Insurance Company:
* Policy Number:
Group Number
* Emergency Phone Number:
 
Parent/Guardian Consent:  
Parental permission must be obtained before medical treatment can be rendered to persons under 18 years of age. The following consent form should be signed by parent or guardian so that indicated care might be given with no necessary delay. No major procedures will be performed except in extreme emergency, without parents being notified and full informed. In the event that a parent does not want treatment rendered under any circumstance, they should cross out the word GIVE on the form below and insert the word REFUSE. If the form is not signed, it will be interpreted as a refusal.
* I
Give
Refuse
permission to the physicians at Gettysburg College to carry out such emergency diagnostic and therapeautic procedures as may be necessary for my son and in the physicians absence for the nurse on duty to render emergency care in line with standing orders, and also permit such procedures to be carried out by one of the local hospitals in the event that my son has been sent or taken there for emergency care.
* Signed:
* Relationship:
Date: