Hoop Camp Medical Forms

Parent or Legal Guardian's Authorization For Emergency Care
*

If a medical emergency arises, I hereby give my consent/authority to the Staff of Hoop Basketball Camp to select a physician and/or hospital for emergency treatment as necessary for my child, with the understanding that I will be notified as soon as possible.
Relationship *
ex. Father, Mother, Legal Guardian
Name of Parent or Legal Guardian *

First Name Last Name
Signature of Parent or Legal Guardian *

Clear
Date *

Month Day Year
Date

Authorization For The Administration Of Over-the-counter (OTC) Medications

ALL OVER THE COUNTER MEDICATION MUST BE IN THE ORIGINAL CONTAINER WITH THE CAMPER’S NAME ON THE BOTTLE. A PARENT’S SIGNATURE IS REQUIRED.
The camp nurse has my permission to give my son/daughter Over-the-counter (OTC) medicine/medicines for the treatment of a fever (100.0 degrees or higher), headaches, muscle strain, or hives/rash. You will be notiﬁed if the problem persists. (Please select at least one option) *

Tylenol Ibuprofen Benadryl I do not consent
How many Over-the-counter (OTC) medications are you providing to be administered? *

Takes no medications 1 2 3
OTC Medication #1 (please fill in the blanks below)
The name of the OTC medication is drug name here*
It is used to treat the following conditione.g., Headache, fever, body aches etc.*
The dosage to be given is total dosage in mg.*
OTC Medication #2 (please fill in the blanks below)
The name of the OTC medication is drug name here*
It is used to treat the following conditione.g., Headache, fever, body aches etc.*
The dosage to be given is total dosage in mg.*
OTC Medication #3 (please fill in the blanks below)
The name of the OTC medication is drug name here*
It is used to treat the following conditione.g., Headache, fever, body aches etc.*
The dosage to be given is total dosage in mg.*
If there is any additional OTC medication information we should please describe below:
Relationship *
ex. Father, Mother, Legal Guardian
Name of Parent or Legal Guardian *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date

Authorization/Approval For Self Administration Of Emergency Medication
PARENTS/GUARDIANS PLEASE READ: By signing this form you are giving permission for your child to administer lifesaving medications without adult or medical supervision of any kind.Do not sign this form unless the child has a life-threatening condition and self-administers his/her own medication. PARENTS/GUARDIANS PLEASE READ: Dosing instructions or any limitations,notes or comments, such as when these devices can or can’t be used, nullifies the document.
As the parent/legal guardian of Name of Camper*, I consent to the following:
During his/her time at camp, the camper is permitted to carry and self-administer the following emergency medication/device. *

Inhaler (rescue inhalers only) EpiPen® (Benadryl is not considered a lifesaving medication) Insulin (including all related diabetic supplies, needles, etc.) Other
Summary of Maine Law on Self-Administration of Emergency Medications

Recreational camps for children; emergency medication. A recreational camp for boys or girls must have a written policy authorizing campers to self-administer emergency medication, including, but not limited to, an asthma inhaler or an epinephrine pen.

The written policy must include the following requirements:

1. A camper who self-administers emergency medication must have the prior written approval of the camper's primary health care provider and the camper's parent or guardian;
2. The camper's parent or guardian must submit written verification to the camp from the camper's primary health care provider confirming that the camper has the knowledge and the skills to safely self-administer
the emergency medication in camp;
3. The camp health staff must evaluate the camper's technique to ensure proper and effective use of the emergency medication in camp; and
4. The emergency medication must be readily available to the camper.
*

I have read the State of Maine Law above, and confirm that the camper has the knowledge and the skills to have readily available and safely self-administer the indicated emergency medication in camp.
*

I will obtain and submit the written authorization / approval verification form from the camper's Primary Care Provider to the Hoop Basketball Camp's Nurse and am aware that failure to do so will nullify the permission to self-administer the indicated emergency medication in camp.
Name of Parent or Legal Guardian authorizing / approving camper's self administration *

First Name Last Name
Relationship *
ie. Father, Mother, Legal Guardian
Name of Parent or Legal Guardian authorizing / approving camper's self administration *

Clear
Date *

Month Day Year
Date
**To be completed by Camp Nurse**
Camp Nurse has reviewed camper’s knowledge and ability to self administer the above medication following outlined procedures in the Hoop Camp policies. (To be completed with camper present)

Yes
Name of Camp Nurse

First Name Last Name
Signature of Camp Nurse

Clear
Date

Month Day Year
Date
Signature

Clear

Release Of Liability And Medical Coverage
*

I understand if a medical emergency occurs, either from sickness or injury, attempts to contact me will be immediate, however, I expressly grant permission for my child to receive medical assistance from the camp nurse and, if I am not located, to transport the camper to a medical facility. I assume all risk and hold the Winter Foundation d/b/a Hoop Basketball Camp harmless from all liability with regard to such sickness and/or injury.
*

I consent to assuming all medical expenses incurred as a result of sickness and/or injuries suffered by my child while attending Hoop Basketball Camp.
Name of Parent or Legal Guardian *

First Name Last Name
Relationship *
ie. Father, Mother, Legal Guardian
Signature of Parent or Legal Guardian *

Clear

Policies and Media Release
Click the links below to read the policy documents:

REFUND POLICY
*

I have read and agree to all terms and conditions of the Refund Policy.
*

I grant permission to Hoop Basketball Camp, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child, myself, and members of my family while at Hoop Basketball Camp for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium. I hereby release Hoop Basketball Camp and its legal representatives from liability for any violation or claims relating to said images or video. Furthermore, I grant permission to use the statements of my child, myself, or my family members given during an interview or evaluation with or without my name for the purpose of advertising and publicity without restriction to time limit or geographic area. I waive my right, my child’s rights, and my family’s rights to any and all compensation stemming from the use of these materials.
Name of Parent or Legal Guardian *

First Name Last Name
Relationship *
ie. Father, Mother, Legal Guardian
Signature of Parent or Legal Guardian *

Clear

Should be Empty:

2022 Hoop Camp Medical Forms

Camper Information

IN CASE OF EMERGENCY NOTIFY:

Primary Care & Health Insurance Information

Health Status Section

Parent or Legal Guardian's Authorization For Emergency Care

Authorization For The Administration Of Over-the-counter (OTC) Medications

Authorization For The Administration Of Prescription Medications

Authorization/Approval For Self Administration Of Emergency Medication

To be completed by Camp Nurse

Release Of Liability And Medical Coverage

Policies and Media Release

2022 Hoop Camp Medical Forms

Camper Information

IN CASE OF EMERGENCY NOTIFY:

Primary Care & Health Insurance Information

Health Status Section

Parent or Legal Guardian's Authorization For Emergency Care

Authorization For The Administration Of Over-the-counter (OTC) Medications

Authorization For The Administration Of Prescription Medications

Authorization/Approval For Self Administration Of Emergency Medication

**To be completed by Camp Nurse**

Release Of Liability And Medical Coverage

Policies and Media Release

To be completed by Camp Nurse