HEALTH HISTORY

1. CAMPER HAS OR IS SUBJECT TO:

ASTHMA____ CONVULSIONS____ FAINTING SPELLS____ DIABETES____

HEART TROUBLE____OTHER (please list and explain): ________________________
______________________________________________________________________
______________________________________________________________________

2. ALLERGIES OR REACTIONS TO:

DRUGS: PENICILLIN___ ASPIRIN____ OTHER____________________________

TETANUS___ DATE OF LAST TETANUS SHOT:___-___-___

FOODS: __________________________________ HAY FEVER:___ IVY OAK:____

INSECT BITES OR STINGS:_______________________________________________

3. CAMPER HAS DIFFICULTY WITH:

EYES, EARS, NOSE, THROAT____ DIGESTION___ LUNGS____

BED WETTING____ MENSTRUAL PROBLEMS____
OTHER (please list & explain):_____________________________________________
________________________________________________________________________
________________________________________________________________________

4. CAMPER HAS A CONDITION NOW REQUIRING MEDICATION: YES___ NO____

If yes, please indicate what condition and what type of medication and
dosage:__________________________________________________________________
________________________________________________________________________
Is the medication in possession of camper? ___yes ___no____

5. PLEASE LIST ANY ACTIVITIES TO BE RESTRICTED: ________________________

________________________________________________________________________

6. MY CHILD MAY PARTICIPATE IN:

SWIMMING: yes___ no____ DIVING: yes___ no____

The Peak Performance Hockey Camps does not require a signed medical release
from the camper’s physician.

PARENTAL AUTHORIZATION
The health history listed above is correct as far as I know, and the above named camper has my permission
to engage in all program activities except as noted. If a serious injury or illness develops, medical and or
hospital care will be given. Staff members are not responsible in case of accidental injury or illness. Further,
I understand that in case of medical emergency I will be notified. In the event that I cannot be reached, I
hereby give my permission to the attending physician to hospitalize, secure proper treatment for, and to order
injection, anesthesia, or surgery for the child named above.

SIGNATURE OF PARENT/GUARDIAN:_____________________________________ DATE:____________________

THIS FORM MUST BE MAILED BACK! Do Not Fax It - We Need This Original Copy!

RETURN THIS FORM PRIOR TO MAY 15, 2010