Intercollegiate Athletics

PARENT CONSENT FORM FOR PARTICIPATION IN ROADRUNNER VOLLEYBALL CAMP

DATE:_________________________________

I, _________________________________________, being the parent or legal guardian of

___________________________________________ give my consent for my daughter to participate in

the Roadrunner’s Volleyball Camp. I hereby agree that I will not hold Roadrunner Volleyball Camp nor

its employees responsible for any loss, damages, or personal injuries received as a result of participation.

_______________________________________

Parent or Guardian Signature

_______________________________________ Address

_______________________________________ City State Zip

_______________________________________ Home Phone

_______________________________________ Work Phone

Campus Box 9 P.O. Box 173362

Denver, CO 80217-3362 303-556-8300

Fax: 303-556-2720

Metropolitan State University of Denver

Health Form

Please fill out in complete form, All information requested.

You will not be allowed to participate in the clinic unless all information has been filled out completely!

Name:_______________________________________________________________________________

Address:______________________________________________________________________________

Phone:____________________________________________ Age:___________________ Birthdate:_______________________

Name of parent or guardian:______________________________________________________________

EMERGENCY CONTACT

Name:___________________________________________ Relationship:_____________________ Telephone: Home:____________________ Work:_______________________

Date of last physical:_________________________________________________________ Date of last tetanus shot:______________________________________________________

Please check if you have the following conditions: Diabetes:__________ Onset:__________ Insulin dependent?:____________________________________ Epilepsy:__________ If yes, are you on medication (please list medication)? _______________________________________________________________________________ Heart conditions:__________ If yes, please list condition:_________________________________________________________ Do you have any restrictions:________________________________________________________

Medications:________________________________________________________________ ________________________________________________________________

Absence of organ:__________ If yes, do you have restrictions?_________________________________________________________ _________________________________________________________________________________ Asthma:__________ Do you require the use of an inhaler?:_________________________ Please list the type of inhaler:________________________________

Other:________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Do you wear contacts: yes:__________ no:_________

Please list any medications that you are currently taking: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please check if you have had the following injury within the last year:

Yes No Injury If yes, please describe:

____ ____ Ankle sprain _______________________________________ ____ ____ Knee injury _______________________________________ ____ ____ Back injury _______________________________________ ____ ____ Head injury _______________________________________ ____ ____ Neck injury _______________________________________ ____ ____ Elbow injury _______________________________________ ____ ____ Wrist injury _______________________________________ ____ ____ Shoulder injury _______________________________________

If you have had surgery on the following injuries, you must have a release from you attending physician!

I, ______________________________ acknowledge that all the information provided on this medical form is to be true. I understand that I will be asked to leave the clinic should any information be found to be untrue.

_______________________________________ _______________________ Signature Date

_______________________________________ _______________________ Parent’s Signature Date