UNIVERSITY OF ILLINOIS at URBANA-CHAMPAIGN, Summaries of Surgical Pathology

Download UNIVERSITY OF ILLINOIS at URBANA-CHAMPAIGN and more Summaries Surgical Pathology in PDF only on Docsity! Revised 3/13/2012 Parents/Guardians must complete and sign this form in order to finalize a campers registration and allow participation in camp activities A doctor’s physical exam is not necessary--only general medical information is required (OVER) UNIVERSITY OF ILLINOIS at URBANA-CHAMPAIGN EMERGENCY MEDICAL INFORMATION (*Summer Sport Camp Fax Number – 217-244-0014) (Please list the CAMP NAME / CAMP DATES for each session in which the camper is currently registered) CAMP NAME: ___________________________CAMP DATES: ________________ CAMP NAME: ___________________________CAMP DATES: ________________ *CAMPER INFORMATION: NAME: _____________________________________________________________________________________ DISABILITY: _____________________________________________________________________________ ADDRESS: __________________________________________________________________________________ Number / Street City State / Zip Code AGE: ___________ GENDER: ________ DATE OF BIRTH: ______/______/______ *PARENT/GUARDIAN/OTHER: NAME: _____________________________________________________________________________________ Relationship HOME PHONE: (_____) _________________________WORK/CELL PHONE: (_____) ______________________ ADDRESS: __________________________________________________________________________________ Number / Street City State / Zip Code *EMERGENCY CONTACT: NAME: _____________________________________________________________________________________ Relationship HOME PHONE: (_____) __________________________WORK/CELL PHONE: (_____) _____________________ ADDRESS: __________________________________________________________________________________ Number / Street City State / Zip Code *HEALTH INFORMATION STATEMENT: Check below any information you feel the staff may need to maximize the safety and the well being of the attendee. To the right of the condition statement is space for more information relating to the condition checked. Please be specific. In case of emergency, this health information may be the only source of accurate important information. This information is confidential. [ ] Neurological Disorders (epilepsy, emotional stress, convulsion)_____________________________ ___________________________________________________________________________________ [ ] Lung Disease (asthma, persistent cough, tuberculosis) ___________________________________ ___________________________________________________________________________________ [ ] Disease of Heart or Blood Vessels, Increased or Abnormal Blood Pressure____________________ ___________________________________________________________________________________ [ ] Pain in Chest or Shortness of Breath (heart murmur, rheumatic fever) ________________________ ___________________________________________________________________________________ [ ] Stomach or Intestinal Trouble (ulcers, gall bladder or liver disorder, jaundice, hernia, colitis) ___________________________________________________________________________________ [ ] Arthritis, Kidney or Bladder Disease___________________________________________________