BOSTON COLLEGE BOYS BASKETBALL CAMP

Transcription

1 BOSTON COLLEGE BOYS BASKETBALL CAMP 2015 APPLICATION Conte Forum 224 Camp phone: Dan McDermott, Director Chestnut Hill, MA MBB Office: Evan Librizzi, Assistant Director Fax: Please submit one application per camper (print clearly and complete all sections): Camper s last name Camper s first name School grade in fall 2015* Date of birth Age *Students who have completed 7 th grade are not eligible to attend Session II (July 27 th 31 st ) of camp due to NCAA rules Camp applications will be accepted on a first come, first serve basis. Upon full capacity, parents will be notified and camper put on waiting list Address City State Zip Parents names Home phone Work phone Cell phone (Please check each of the following sections) Session Dates: Tuition: Deposit enclosed: Payment: О Session I (June 22 nd 26 th ) О $ (one week) О $ (one week) О *Online О Session II (July 27 th 31 st ) О $ (two weeks) О $ (two weeks) О Check enclosed *PLEASE NOTE: Online payment does not guarantee registration until all mandated forms are received into the camp office. No cash or phone registration accepted. Please make checks payable/mail to: BC Boys Basketball Camp, Conte Forum 224, Chestnut Hill, MA Carpool: Yes, I d like my name, address and phone number added to the carpool list and a final list mailed to me. * If possible, place with one (1) friend: (Placement is not guaranteed). * PLEASE NOTE: option available only to campers fully registered one month prior to session attending. Person to call in case of emergency (other than parent) Relationship Telephone Cell phone Health insurance carrier Policy/group number Subscriber All non-medical related refund requests must be submitted in writing to the camp administrator on or before June 8 (for Wk 1) or July 13 (for Wk 2). All approved refunds will be processed less the $ non-refundable, non-transferable deposit(s). Medical related refund requests will be accepted up to the first day of camp and approved refunds will receive a full refund. A letter from the child s physician explaining the nature of the illness or injury must accompany the parent s written request. No refunds granted for any reason after the first day of camp. By signing this application, I hereby acknowledge that I have read, understand and agree to all of the terms set forth in the 2014 Boston College Boys Basketball Camp brochure and application regarding its registration, cancellation and refund policies. I understand that, in order for this application to be accepted, all required forms (including an updated Physician s Health Form and Immunization Report) and a non-refundable/nontransferable deposit/or full payment must be received at time of application. X Parent/Guardian Signature: Date

2 REQUIRED FORM Boston College Boys Basketball 2015 Camp Waiver (FORM A) The named camper has my permission to participate in the camp program. In case of an emergency, I understand that every attempt will be made to contact me and/or the emergency contact person listed below. If contact is unsuccessful, I give permission to the attending physician to render medical treatment to the participant, including (if necessary) hospitalization. Any expense arising from injury is the responsibility of the parent/guardian signing below. The Health History provided is correct to the best of my knowledge, and the child described herein has permission to engage in all prescribed program activities except as noted by the examining physician and me. I hereby authorize the medical staff of Boston College to provide medical care that may include routine diagnostic procedures (i.e. x- rays, blood and urine test) and treatment as necessary to my minor son. I understand that the consent and authorization herein granted does not include major surgical procedures and shall be valid only during the 2015 camp session(s). Please list all physical conditions that the clinician should be aware of prior to treatment: (allergies, recurring illnesses, injuries, disabilities, chronic illnesses, etc.) Date of most recent tetanus immunization: (A Tetanus booster is required of all students and staff entering the seventh tenth grade, if more than 5 years (camper) or 10 years (staff) since their last DTaP/DTP/DT shot) Accident insurance for the 2015 Boston College Boy s Basketball Camp is provided by Boston College on an excess basis. All registrants must have their own primary medical insurance. Any medical costs and expenses will be the primary responsibility of the parent or guardian s medical coverage. I, the undersigned parent and/or legal guardian of the participant listed above, do hereby consent to his participation in the program identified above. I, as the parent/guardian of the participant and on behalf of the participant release, hold harmless and agree to indemnify Trustees of Boston College and each of their respective members, partners, officers, directors, faculty, staff, representatives, affiliates, employees and agents, as applicable, from and against any present or future claim, loss or liability for injury to person or property which I or the participant may suffer, or for which the Participant may be liable to any other person, related to their participation in the program (including periods in transit to or from the participant s destination), resulting from any cause, including but not limited to ordinary or gross negligence. (Please print clearly) Name of Participant: Name of emergency contact: Emergency phone #: Cell #: Insurance company: *Insurance Co. Address: Phone #: Name of subscriber: Policy #: Signature of Parent/ Guardian Date * Insurance Company address and phone number can usually be found on the back of the insurance card.

3 Boston College Boys Basketball Camp (FORM B) REQUIRED FORM 1. MEDICAL TRAINER S COPY LAST NAME: FIRST NAME: DOB: AGE: HGT: WGT: GRADE: (in 9/15) PARENT/GUARDIAN: DAY/WORK PHONE: CELL PHONE: 2. HEALTH HISTORY Illness: *Allergies: Disease: Frequent Ear Infections: Hay Fever: Chicken Pox: Heart Defect/Disease: Ivy Poisoning: Measles: Convulsions: Medicine: G. Measles: Diabetes: Foods: Mumps: Bleeding/Clotting Disorders: *Insect Stings: Chronic or recurring illness: *Type Insect: Concussion(s): If yes, number & time lost: *Asthma: * Please describe care necessary to handle asthma (i.e.-use of inhaler, etc.): * If Epi-Pen is required to handle allergic reaction, family must supply. Operations or serious injuries (w/dates): Specific activities to be restricted: Dentist: Phone: Doctor: Phone: Medical Insurance Carrier: Policy #: Address: Phone: 3. AUTHORIZATION TO ADMINISTER MEDICATION PLEASE NOTE: SECTION III MUST BE COMPLETED AND SIGNED REGARDLESS OF YOUR CHILD S NEED FOR MEDICATION CHECK ONE: YES, my son requires medication at camp NO, my son does not require medication If yes, please provide the following information: Food/drug allergies: Diagnosis (@ parent s discretion): **Name of medication(s): Name of licensed prescriber: Date ordered: Qty. Rec d: Expiration date: Special storage requirements: Camp dosage: Frequency: Specific precautions: Specific instructions (by mouth, empty stomach, etc.): Duration: Possible side effects/adverse reaction: Specific precautions: Where/how to administer: Name(s) of other medication(s) being taken: Circle: OTC/ Prescription According to the Department of Health , Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows the date of filling, the pharmacy name and address, the filling pharmacist s initials, the serial number of the prescription, the name of the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statements, if any, contained in such prescription by law, and if tablets or capsules, the number in the container. All over the counter medications for campers shall be kept in the original containers containing the original label, which shall include directions for use. When no longer needed, medications shall be returned to the parent or guardian whenever possible. If the medication cannot be returned, it shall be destroyed. The directions given on this form regarding the administration of my son s medication is accurate. I give authorization for the medical staff at the Boston College Boy s Basketball Camp to administer the medication listed on this form to my child:. ** Parent/guardian must deliver medication(s) to & meet with Medical Trainer at Monday morning check-in (i.e.-epi pen, inhaler, etc.) X PARENT SIGNATURE: Date: Revised 01/12

4 REQUIRED FORM Boston College Boys Basketball Pick-up Authorization (FORM C) Additional names may be added or deleted at any time by submitting written notice signed & dated by parent or guardian to the camp administrator Mandated by Massachusetts State Law 105 CMR (B), please provide a list of the individuals who will be authorized to pick-up the named camper. No camper will be released to an individual who is not listed. In case of a last minute change, a camper s parent must call the camp administrator at by 1:00 p.m. on that day. Camper s Name: Authorized Individuals (Parent(s) and/or guardian(s) must also be listed): (Please print clearly) (Use back for additional space if needed) Health Care Policy Guidelines Mandated by Massachusetts State Law 105 CMR (B), the following appropriate care will be administered to participants by the medical staff: Mildly ill campers will be evaluated by the medical staff in the Sports Medicine Training Room at Boston College. Treatment will be administered per standing order and the Health Care Consultant will be notified if necessary. If condition persists or worsens, appropriate care will be administered and the parent/guardian will be notified. Prescription medications will be administered only after parents complete and sign the Authorization to Administer Prescription Medications form. Athletic trainers will be responsible for storing and daily administration of appropriate dosages. Emergency Care: An athletic trainer will be on site for all activities. They will evaluate need for activation E.M.S. system. For emergency injuries, Boston College Campus Police will be contacted for ambulance transport and parent will be notified. Yes, I have read the above mentioned health care policy guidelines. Yes, I understand that only those people listed on the above pick up authorization form will be allowed to pick up my son and should I need to alter the list, I must first notify the camp administrator in writing. X Parent/Guardian Signature Date Revised: 01/13

5 PHYSICIAN S HEALTH/IMMUNIZATION REPORT (FORM D) REQUIRED FORM This form or physician s facsimile, if compatible, must be submitted with the camp application. CAMPER S NAME: Date of last physical exam: DOB: IMMUNIZATION HISTORY: (History must comply with the requirements set forth by The State of Massachusetts/Health Dept., as listed on the back of this form) DPT Polio MMR (combined) Meningococcal (suggested, but not required) ** ** A third vaccine is required if first vaccine given prior to first birthday. * 5. * Booster: (See below & back for details) History of Chicken Pox HIB Hepatitis B Series Varicella Yes Date No 3. *3. 4. * Third dose required for children born on or after 1/1/92. *A Td Booster is required for children entering grade 7 th 10 th, if more than 5 years since their last DTP vaccine. Child s immunization report must comply with the State of Massachusetts Board of Health, Immunization Rules & Regulations as listed on the back of this form. The State Health Inspector can/ will remove improperly inoculated children from camp at the parent s expense (no refund). It is the parent s responsibility to insure that all vaccination requirements have been met prior to submitting their child s camp application. No child will be allowed to begin camp without the proper inoculation documentation. MEDICAL/HEALTH Examination: To be filled in and signed by a licensed physician. A full examination should be performed within a two (2) calendar year period to cover BC Camp end date of 8/1/14. Examination for some other purpose within a one (1) period is acceptable. In event of an emergency, list any/all condition(s) that Medical Trainer should be aware of prior to treatment. Code (circle one): V-Satisfactory X-Not Satisfactory (explain) O-Not Examined Hgt. Wgt. Blood Pressure: Urinalysis: Eyes: Lungs: Nose: Skin: Glasses: Contacts: Head (Concussion): Ears: Hernia: Posture (spine): Extremities: Throat: General Appraisal: Heart: Skin: Specific Restricted Activity: Genitalia: Abdomen: Cardiovascular disease: Musculoskeletal Injuries (explain): *Asthma: *Allergy: * Describe allergic reaction/treatment: *Current Medications: * Parent(s) must meet with and deliver medication(s) to the Medical Trainer during Monday morning check-in. (i.e. Epi-pen, inhalers, etc.) Special Diet: I have examined the person described herein and have reviewed his health history. It is my opinion that this child is physically able to engage in all program activities, except as noted above. Physician s Signature: Date: Print Name: Address: Phone Revised: 01/13

6 PLEASE READ IMPORTANT IMMUNIZATION INFORMATION LISTED BELOW Memorandum from: THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES DEPARTMENT OF PUBLIC HEALTH DIVISION OF COMMUNITY SANITATION 305 South Street, Jamaica Plain, MA (617) Listed below you will find information regarding changes to recreational camp for children, regulation and policy. All documents including the final, complete copy of the regulations will also be available at : Required Immunization Written documentation of immunization shall be required for all campers and staff as follows: (A) For Campers and Staff under 18 years old: Measles, Mumps and Rubella (MMR) Vaccine: A minimum of one dose of MMR vaccine(s) must be administered at or after 12 months of age. A second dose of live measles-containing vaccine, given at least 4 weeks after the first, is required for all campers and staff, who will be entering grades K-12 or college in the school year immediately following the camp session. *Children given a first MMR vaccine prior to their first birthday will require a third vaccination. Polio Vaccine: A minimum of 3 doses of either inactivated polio vaccine (IPV) or oral polio vaccine (OPV) are required. If a mixed IPV/OPV schedule was used, 4 doses are required. Diphtheria and Tetanus Toxoids and Pertussis Vaccine: A minimum of 4 doses of DTaP/DTP/DT or at least 3 doses of TD is required. Where a camper or staff person is seven or more years of age and requires additional immunizations to satisfy 105 CMR (A) (3), Td is to be substituted for DTaP, DTP or DT vaccine. Effective January 1, 2004, a booster dose of Td is required for all campers entering grades seven through ten if it has been more than five years since their last dose of DTaP/DTP/DT. Certificate of Td inoculation must be listed on the Physician s Health Evaluation and Immunization Record form. Hepatitis B vaccine: For all children born on or after January 1, 1992, three (3) doses of Hepatitis B vaccine are required. Laboratory evidence of immunity is acceptable. Varicella: 2 doses