Price $0.00 Athlete's First Name * Athlete's Last Name * Athlete's Email * Athlete's Cell Phone * School Name * Grade * - Select a value -TKK12345678910111213 Gender * Female Male Birth Date * Date E.g., 06/18/2022 Medical InformationNotice Dordt University does not employ or provide nursing or medical personnel on campus during academic or athletic camps. Medical emergencies, if any, are addressed through local emergency medical response personnel. Emergency Authorization/Consent to Medical Treatment By signature below, I authorize Dordt University and its representatives, if present, to provide to my child, through medical personnel of their choice, customary medical assistance, transportation, and emergency medical services should my child require such assistance, transportation, or services as a result of injury, illness or damage while participating in or related to my child's participation in camp. This consent does not impose a duty upon Dordt University or its representatives to provide such assistance, transportation, or services. Financial Responsibility By signature below, I accept financial responsibility for all medical treatment provided to my child at Dordt University's request. I also understand and acknowledge that Dordt University is not responsible for administering any medications to my child. Applicable Law Because Dordt University is located in the state of Iowa, and in order to provide certainty in the law to be applied to the construction of this instrument, this Consent shall be governed, construed and enforced in accordance with the law of the State of Iowa. Physician's Name * Physician's Phone * Insurance Provider * Insurance Policy ID * Primary Name on Insurance Policy * Insurance Plan ID Allergies Describe any allergies you have. Medical Conditions Describe any medical conditions you have. Medications List any medications you are currently taking. Parent/Guardian Signature * Please enter your full name. Parent/Guardian Information Full Name * Address Line 1 * Address Line 2 City State/Province * - Select a value -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Zip/Postal Code * Country * United StatesCanadaOther Phone * Parent/Guardian Email * Alternate Emergency Contact Full Name * Phone * Cell Phone Relationship to Participant * Disclaimer * I give permission to Dordt University to take and use photos, videos, and audio recordings of the participant(s) for educational, advertising and promotional materials unless I contact the public relations office at email@example.com to specifically opt out. * I agree to abide by the rules set forth in the Sports Camp Manual. * I consent to the Release of Liability, Waiver, and Indemnification.