Health History Form

First Name

Last Name

Address

City, State, Zip

Date of Birth

Email address

Phone Number

Host Family

Host Family Phone Number

Family Doctor

Family Dcotor Phone Number

Emergency Contact

Emergency Contact Phone Number

Health Insurance Company

Policy Number

If you checked any of the conditions listed, please explain

Have you been sick in the last 3 months that required seeing a doctor?

List any medication that you are taking including supplements

When was the last physical exam you had by a physician?

How would you describe your eating habits, how many deals daily?

Are you now, or have you ever been on a diet (explain)?

BUXMONT TORCH ATHLETIC WAIVER

The BuxMont Torch personnel have devoted great effort to assure that participating athletes are protected in every way possible. However, participation in athletics includes a risk of injury, which may range in severity from minor to catastrophic, including paralysis, mental disability, and death.

Participants have the responsibility to help reduce the chance of injury. Participants must obey all safety rules and regulations, report all physical problems to the coach and athletic trainer, follow a proper conditioning program, and inspect personal protective equipment daily. Proper execution of skill techniques must be followed. Any and all injuries resulting from participating on an athletic team will be submitted to the primary insurance company of the student-athlete and then to the secondary policy provided through the USASA (See “Insurance Information”). Any deductibles or costs incurred beyond insurance coverage will be the responsibility of the insured.

I Agree To The Buxmont Torch Athletic Waiver Above

PARENT/GUARDIAN STATEMENT

I consent to have my son/daughter represent BuxMont Torch FC in approved activities except those activities excluded by the examining physician.

I grant permission for my son/daughter to accompany any BuxMont Torch FC team of which he/she is a member to out-of-town trips. The athlete will be transported to and from all events in BMT approved vehicles

In the event of an emergency requiring medical attention, I expect every reasonable attempt to be made to contact me. In case I cannot be reached, I grant permission for any immediate treatment deemed necessary by the attending physician and transfer of my son/daughter to a qualified medical facility. This authorization does not cover major surgery unless formally decreed prior to surgery by two licensed physicians or dentist.

I agree not to hold BuxMont Torch or anyone acting on its behalf responsible for any injury occurring to my son/daughter in the course of such athletic activities or travel, whether, as a result of my son’s/daughter’s negligence, the negligence of others, or the negligence of the ministry.

I acknowledge and accept that there are risks of physical injury involved in athletic participation which may result in permanent paralysis, mental disability, and death.

I Agree To The Parent/Guardian Statement Above

Parent Name

Parent Phone Number

Date

STUDENT-ATHLETE STATEMENT

I agree not to hold BuxMont Torch or anyone acting on its behalf responsible for any injury occurring to me in the course of such athletic activities or travel, whether as a result of my negligence or the negligence of others.

I acknowledge and accept that there are risks of physical injury involved in athletic participation which may result in permanent paralysis, mental disability, and death.

I grant permission for BuxMont Torch FC to notify my parent/guardian in case of injury or illness when they deem necessary according to the situation.

I Agree To The Student-Athlete Statement Above

Student-Athlete Name

Date

Are you human?(required)

Information

Camps

Men’s NPSL

Women’s WPSL

Torch Sports Ministry

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