Speed and Hurdle Intensive Camp First Name *Last Name *Email Address *Date of Birth *Gender *SelectMaleFemaleAs a student, parent or guardian, I understand that the information requested on this form is intended to help inform program staff of any pre-existing medical conditions. If Participant has a pre-existing medical condition, participation in any strenuous activities or recreational time may not be recommended. This information will be kept in strict confidence and will only be shared with your permission. Agility Counseling Group requests the information below so that, in case of emergency, we will have accurate information so that we can provide and/or seek appropriate treatment for Participant. You are accountable for providing an accurate medical history. Final determination about whether to participate is the responsibility of you and your physician however the Agility Counseling Group reserves the right to deny participation due to an illness, injury or concussion. If Participant has any medical issue that is not requested below, but which you think is important, please include that information. It is recommended that you consult with a physician prior to participating in this Program. If you are uncertain about any preexisting medical conditions, it is your responsibility to consult with your own physician prior to participating in this Program. Please answer all of the questions. If you answer yes to any of the following questions, please explain as indicated. Use back and/or additional paper if needed. It is recommended that Participant consult with your physician prior to participating in this Program. If you are uncertain about any preexisting medical conditions, it is your responsibility to consult with your own physician prior to participating in this Program. Please answer all of the questions. If you answer yes to any of the following questions, please explain as indicated. Use back and/or additional paper if needed.Physician's Name *Physician's Phone Number *Date of most recent tetanus toxoid immunizationDo you have health/accident Insurance *YesNoDoes participant have any limiting medical conditions that you or your doctor feel would limit camp? *SelectYesNoIs participant currently taking medication that may interfere with ability to safely participate in program *SelectYesNoDoes participant have a history of allergies or reactions to medications, insect stings, or plants *SelectYesNoDoes participant have a history of, or currently suffer from, medical condition(s) with which we need to be aware *SelectYesNoThis form must be completed fully in order for the participants to self-administer required medication. A new medication administration form must be completed for each program attended by the participant for each medication, and each time there is a change in dosage or time of administration of a medication. Self-medication requires licensed health care authorization and signature, and parent signature.My child will need to take prescription medication while at the Program *SelectYesNoParent/Guardian InformationName *Cell Phone *Emergency Contact InformationName *Cell Phone *Relationship To Participant *Insurance InformationInsurance Company Name *Insurance Company Phone *Policy & Group # *Policy Holder Name * Please read the following waivers and agreements carefully Review the following policies carefully before continuing. Your electronic signature confirms that you have read and agree to all terms and conditions, including any liability waivers and refund policies.I agree to the Ohio Department of Health Concussion Information Sheet For Interscholastic AthleticsI agree to AUTHORIZATION FOR MEDICAL CAREI agree to the Event Waiver AgreementI agree to the Medication WaiverRefund policy: No refunds. (Participants will use on-campus gym if needed for inclement weather)I grant permission for my child to be photographed and/or recorded during camp activities. I understand these images or recordings may be used by the camp for promotional, educational, or marketing purposes, including social media, websites, and printed materials.$150 Payment for Speed and Hurdle Intensive CampCredit / Debit Card *Submit
