SVSU Volleyball AAU Tournament Form - Please Complete for Youth Participant - Saginaw Valley State

Email address *

Team Name *

Please choose your team name from a list below

Name of Athlete *

Address *

City *

State *

Zipcode *

Date of Birth *

xx/xx/xxxx

Primary Care Physician *

Physician Office Phone # *

(xxx) xxx-xxxx

Is camper currently being treated by a physician for injury or illness? *

List medical conditions *

List medications currently taken *

List allergies *

Insurance Company *

Policy # *

Policy Holder's Name *

Home Phone # *

(xxx) xxx-xxxx

Emergency Contact Person *

Relationship to Camper *

Emergency Phone # *

(xxx) xxx-xxxx

Disclaimer *

As the parent/guardian of the camper listed above I hereby agree to the following as a condition of my child's participation in the Saginaw Valley State University (SVSU) summer camp program and related activities. I give my permission to SVSU to provide, seek, obtain or approve any routine, necessary or emergency health care during the camper's involvement in the SVSU summer camp program. I understand that this authorization is given in advance of any specific consent to any and all such diagnosis, treatment or medical care being required and is to serve as specific consent to any and all such diagnosis, treatment or hospital care which may be deemed advisable. I understand my rights under the Health Insurance Portability and Accountability Act (HIPAA) and authorize SVSU to release information as necessary for managing summer camp healthcare. I attest that a physician has examined the camper in the past twelve months and he/she was found to be in good health. I understand and agree that SVSU may in its sole discretion, decide to refuse participation by the camper based on disclosure of medical condition. I attest that currently there is no medical reason for the camper not to participate in the strenuous physical activities of the sports camp program. I acknowledge that participation in sports camp and related activities involves an inherent risk of personal injury. I assume such risk on behalf of the camper and give my permission to the camper to participate in all sports camp activities. I release and agree to hold harmless SVSU, its Board of Control, students and employees from all claims, actions, damages and liabilities for personal injury or damage relating or arising out of any sports camp activity except where the injury or damage relating to or arising out of any sports camp activity is caused by the gross negligence of the university's employees. I understand the camper will be subject to the rules and regulations of the SVSU sports camp. I understand that any person who repeatedly disobeys camp policies or procedures will be immediately expelled from the camp. I understand that by printing my name in the area below I am submitting my online signature

Date *

xx/xx/xxxx

What is a concussion? *

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head or body that causes the head and brain to move quickly back and forth. Even a "ding," "getting your bell rung," or what seems to be a mild bump or blow to the head can be serious.