Boot -Camp Registration Fom

PLEASE PRINT THE FOLLOWING INFORMATION
                 
Name of Recruit: _____________________________________________Age:_________________
Parent(S) or Guardian(s): ___________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Address: __________________________________________________________________________
City, State, Zip Code: _______________________________________________________________
Home Phone: (___)_____________________________Business Phone:(___)_________________
Emergency Number(s): (___)_______________________________Cell: (___)_________________
                 
      ** In case of emergency, I give permission to the camp administrators to authorize 
the necessary medical attention recommended by physicians or hospital staff.  
                 
____________________________________   ____________________________________
(Print Parent(s)/Guardian(s) name)   (Parent(s)/Guardian(s) signature)
                 
Has this athlete ever been medically advised not to participate in any sports?  
__________________________________________________________________________________
                 
Do you have any worries about the Recruit’s health or think there may be reason why the 
Recruit should not participate in the camps?        
__________________________________________________________________________________
                 
                 
I will assume all responsibility for injuries that my child may sustain during Camp.  
I hereby authorize the staff of the Howell PAL Camp to act for me according to their best
judgement in any emergency situation requiring medical attention and hereby release
the Staff and the Howell PAL harmless of any injuries or illnesses my child may have   
while attending the Camps.            
Within the last year – Please answer Yes or No.          
Sprains   If yes, where?          
Fractures   If yes, where?          
Dislocations   If yes, where?          
Concussions   If yes, where?          
Vascular/Nerve Conditions            
               
Other health conditions – Please answer YES or NO.          
Diabetes   Mononucleosis     Heart Condition  
Epilepsy   Asthma     Heat Related Conditions
Lyme Disease              
Other Conditions Medical Staff Should be aware of           
               
Allergies – Please answer YES or No.          
Hay Fever     Food Peniclilin       
Insect Stings     Other      
Medication(s) Recruit will be taking at camp:          
Parent/Guardian            
Signature              
               
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TEAR OFF              
GENERAL INFORMATION  Monmouth Fire Academy 6/28-7/2
1.  Arrive on time and promptly be picked up at 2:00 p.m.          
2.  Recruits should wear suitable clothing, hat, sneakers.  Also bring multipurpose      
3.  Recruits should bring water bottles with names on bottles.          
4.  Bring pen, pencil and paper.          
Send application to: Howell PAL          
    PO Box 713          
    Howell, NJ 07731