Tag: conditions

Here’s a Neftaly Medical History Form template for capturing relevant health information about participants, ensuring their safety during the camp:

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Neftaly Basketball Camp: Medical History Form

Participant Information

• Full Name:
  (First Name, Last Name)
• Date of Birth (MM/DD/YYYY):
  (e.g., 01/15/2005)
• Age:
  (Please specify the age of the participant)
• Gender:
  ☐ Male
  ☐ Female
  ☐ Other
  ☐ Prefer not to say

Parent/Guardian Information (If Under 18)

• Parent/Guardian Full Name:
  (First Name, Last Name)
• Parent/Guardian Email:
  (Email address)
• Parent/Guardian Phone Number:
  (Contact phone number)

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Health History

1. Do you have any of the following conditions?
   (Check all that apply)
   • ☐ Asthma
   • ☐ Diabetes
   • ☐ Seizures
   • ☐ Heart conditions
   • ☐ Allergies (Please specify): _______________
   • ☐ Blood pressure issues
   • ☐ Respiratory conditions
   • ☐ Fainting or dizziness
   • ☐ Other health conditions (Please specify): _______________
2. Current Medications:
   (Please list any medications the participant is currently taking and the dosage, including inhalers, epi-pens, etc.)
3. Previous Injuries:
   (Please list any injuries sustained in the past that may affect participation, such as sprains, fractures, or joint issues)
4. Surgeries/Operations:
   (Please list any surgeries or operations the participant has had in the past that may affect participation)
5. Physical Limitations or Restrictions:
   (Please describe any physical limitations that might affect the participant’s ability to fully engage in basketball activities)
6. Allergies:
   (Please list any known allergies, including food, medication, or environmental allergies)
7. Immunizations:
   Are the participant’s immunizations up to date?
   ☐ Yes
   ☐ No
   If no, please specify any missing immunizations: _______________
8. Do you have any other relevant medical information?
   (Please provide any other information that may be important for camp staff to know in order to ensure the safety of the participant)

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Emergency Contact Information

• Emergency Contact Name:
  (Full Name)
• Emergency Contact Relationship:
  (e.g., Mother, Father, Guardian)
• Emergency Contact Phone Number:
  (Phone number for emergency contact)

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Waiver and Consent

By signing below, I authorize Neftaly Basketball Camp staff to administer basic first aid in case of injury and contact emergency medical services if necessary. I understand that it is my responsibility to inform the camp of any medical conditions, medications, or concerns that may affect the participant’s ability to participate.

I release Neftaly Basketball Camp from any liability in the event of injury or medical emergency during participation.

• Parent/Guardian Name (If Under 18):
  (First Name, Last Name)
• Parent/Guardian Signature:
  (Signature of parent or guardian if participant is under 18)
• Date:
  (MM/DD/YYYY)

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Physician Information

• Physician’s Name:
  (Full Name)
• Physician’s Contact Number:
  (Phone number)
• Insurance Provider:
  (Insurance company name)
• Policy Number:
  (Insurance policy number)

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This form ensures that the camp can make informed decisions about a participant’s safety and any special accommodations they may need based on their medical history. It also provides important emergency contact information in case of any issues during the camp.