Mercer County Community College Summer Sports Camps
Health History & Medical Authorization
for All Persons Under Age 18
Print this form. Mail the signed, completed form and a completed registration form to:
This form must be completed and returned with the camp registration form. No camp registration will be processed unless accompanied by this medical form. NOTE: A doctor's signature is NOT required.
Contacts & Phone Numbers
Please complete the following:
According to state law, all campers must be immunized or submit a statement from a physician, prior to the first day of camp, that immunization is in progress. (See NOTE below.) Please indicate all immunization dates for each of the following:
If an emergency illness or injury occurs, I (parent/guardian) hereby authorize Mercer County Community College to treat and/or send this person to a physician or hospital and authorize the necessary treatment. I also authorize the physician or hospital to release my child after treatment to a representative of Mercer County Community College.
All information on this form is complete, true and accurate to the best of my knowledge.
Signature of parent or guardian ________________________________________ Date _________________
2. If immunization is contraindicated for medical reasons, the parent or guardian shall submit to the camp a written statement signed by a licensed physician, indicating both the reason and length of the medical contraindication.
A completed copy of this form must be submitted with the camp registration form.
Questions? E-mail email@example.com or call (609) 586-4800 ext. 3779.