Send To: Hockey Techniques    PO Box 401   Oxford, NJ 07863   or Fax to: (908) 453 - 2436
For questions call: (908) 453 - 2436 or email: hocktech@hockey-techniques.com

MEDICAL FORM

(Summer campers only)
(Please Print)

Name _ _ _ _ _ _ _ _ _  _ _ _ _ __ _ _ _ ________________ 
                 (Last)                (First)                (Middle)

Camps Signed up for 
1st camp ______, 2nd Camp ______, 3rd Camp ______

Date of Birth _ _ _ _/ _ _ _ _ / _ _ _ _   
           
Email Address:___________________________________

 IMMUNIZATIONS & OTHER PERSONAL INFORMATION            

                                                Yes          No                                   Date of last dose

Measles                                  _ _ _       _ _ _        Tetanus (Initial,booster)                          _ _ ________
German Measles                   _ _ _       _ _ _        Rubella                                                      ________ __
Seizure Disorder                   _ _ _       _ _ _        Mumps                                                      _ ________ _
Allergies (attach note)          _ _ _       _ _ _        Polio (4 doses,oral,vaccine,sabin)         _ ________ _

Are you on any medications? Yes______ No______ What and Why? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _ _ _ _ _ _

Does your child have ADD or ADHD?_____________         Does your child have any learning disabilities? Yes______ No______ Please explain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _ _ _  

Have you had any significant injuries in the past? (i.e. broken bones, concussions, or any surgery)  Yes _____            No ________

 INSURANCE INFORMATION

Policy Holder: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Policy or Suffix #: _ _ _ _ _ _ _ _ _ _ _______

 Company Policy held with: _ _ _ _ _ _ _ _ _ _ _ _ _ ______________________________________ _

 Relationship to holder: _ _ _ _ _ _ _ _ _ _ _ _ (If HT Worker) SS #: _ _ _ _ _ _ _ _ __ _ _ _____ _ _  

 EMERGENCY INFORMATION (IF PARENT OR GUARDIAN CAN NOT BE REACHED)

Name _ _ _ _ __ _ _ _ _ _ _ __ _ _ _ _ __      Relationship _ _ _ __ _ _ _ _ _ _

 Telephone: Home # (_ ___ _) _ _ ___ _ - _ _ ______ _ _  Work # (_ ___ _) _ _ __ _ - _ _ _ _  _ _ _

 WAIVER

I acknowledge that hockey is a contact sport and the that Todd Drevitch's Hockey Techniques Inc., it's coaches, staff, and agents shall not be made liable to me for any injury or damage incurred while participating in the camp or on the premises at which the camp is held.  Furthermore, I submit that any relative, heir, legal relative from making Todd Drevitch's Hockey Techniques Inc., it's coaches, staff and agents liable for any injury or damage that may occur during or on the premises of the camp.  In addition to this, I give Todd Drevitch's Hockey Techniques Inc. consent to follow proper emergency procedure with my son/daughter.  I attest that the player is in good health and is able to participate in the physical activity of a rigorous camp.

 Signature of Parent/Guardian ___________________________________________

 Print name of Parent/Guardian__________________________   Date: _________________