Medical/Registration Form

Participants Information:

First Name:

Middle Name:

Last Name:

Date of Birth:

Address:

City:

State:

Zip Code:

Insurance Information

Insurance Name:

(Ex: Blue Cross/Blue Shield, Humana)

Type:

(HMO, PPO, Military)

Primary Card Holder:

ID/Policy #:

Group/Network #:

Verification #:

(Ex....1-800)

Medical Information

Medical conditions/concerns:

Allergies to food, pollen, medicine, etc

Current Medications:

I acknowledge that the participant's
immunizations are current:

Emergency Contact Information

Name (not parent/guardian):

Relation to Participant:

Address:

Street Address, City and State Please

Emergency Contacts Phone Numbers:

Home:

Work:

Cell:

Consent to Receive Treatment:

Participant's Full Name:

Plans to attend the Odell James Football Camp (OJFC). I fully understand that injury or illness could result from or during participation in the OJFC. In case of accident or illness, I give my permission to receive medical treatment as deemed necessary by the sports medicine staff. I will assume all responsibility for any medical bills.

Adult Participant or Parent/Guardian's Name:

Adult Participant or Parent/Guardian's Signature:

Date:

Registration Form.

Both Forms Must be Filled out.

Athlete's Full Name:

Athlete's Street Address:

City:

State:

Zip Code:

Area Code/Home Phone Number(s):

Cell Phone:

Email Address:

Parent's Name:

Any home information different from athlete's:

High School:

Grade (as of upcoming Fall):

Position:

Quarterback
Running Back
Wide Receiver
Tight End
Offensive Lineman
Defensive Lineman
Linebacker
Defensive Back
Kicker/Punter

Yrs. played position:

Height:

Weight:

40 time:

Vertical Jump:

T-shirt size:

Small Medium Large X-Large XX-Large XXX-Large

Please check one:

Commuter, early registration, $150
Overnighter, early registration, $200
Commuter, $175
Overnighter, $225

Medical/Registration Form

Below you will find the Medical Release Form and The Registration Form.

Both Forms Must be Filled out.

Registration Form.

Both Forms Must be Filled out.