Wednesday, June 19th, 2013
First Name (required):
Last Name (required):
MEDICATIONS BEING TAKEN
Please list ALL medications (including over the counter or non-prescription drugs) taken routinely. Use of any medication is solely the responsibility of the camper and/or his/her parents/guardian while away from Club property. Please note: Nassau Racquet & Tennis Club employees will not administer any medications, nor will any medications be stored on the premises.
This person takes NO medications on a routine basis. This person takes medications as follows:
Med #1 Dosage Specific Times taken each day
Reason for taking
Med #2 Dosage Specific Times taken each day
Reason for taking
Med #3 Dosage Specific Times taken each day
Reason for taking
RESTRICTIONS (The following restrictions apply to this individual)
Does NOT eat: Red meat Pork Dairy Poultry Seafood Eggs Nuts Other
Explain any restrictions to ACTIVITY (e.g. what cannot be done, what adaptations or limitations are necessary)
GENERAL QUESTIONS (Explain “yes” answers below)
Has/does the participant:
1. Had any recent injury, illness, or infectious disease? Yes No
2. Have a chronic or recurring illness/condition? Yes No
3. Ever been hospitalized? Yes No
4. Ever had surgery? Yes No
5. Have frequent headaches? Yes No
6. Ever had a head injury? Yes No
7. Ever been knocked unconscious? Yes No
8. Wear glasses, contacts or protective eye wear? Yes No
9. Ever had frequent ear infections? Yes No
10. Ever passed out during or after exercise? Yes No
11. Ever been dizzy during or after exercise? Yes No
12. Ever had seizures? Yes No
13. Ever had chest pain during or after exercise? Yes No
14. Ever had high blood pressure? Yes No
15. Ever had back problems? Yes No
16. Ever had problems with joints (e.g., knees, ankles)? Yes No
17. Use an orthodontic appliance at camp? Yes No
18. Have any skin problems (rash, itching, acne)? Yes No
19. Have diabetes? Yes No
20. Have asthma? Yes No
21. Had mononucleosis in the past 12 months? Yes No
22. Had problems with diarrhea/constipation? Yes No
23. Have problems with sleepwalking? Yes No
24. If female, have an abnormal menstrual history? Yes No
25. Have a history of bed-wetting? Yes No
26. Ever had an eating disorder? Yes No
27. Been treated for emotional issues by a professional? Yes No
28. Ever been diagnosed with a heart murmur? Yes No
Please explain any “yes: answers, noting number of question(s):
Which of the following Has the participant had?
Measles Chicken Pox German measles Mumps Hepatitis A Hepatitis B Hepatitis C
Please give all dates of immunization below or drop of immunization form from your child's doctor at the club (please note - immunization records are required before your child can attend camp):
DTP (MM/YY): , , , , ,
TD (tetanus/diphtheria) (MM/YY): , , , , ,
Tetanus (MM/YY): , , , , ,
Polio (MM/YY): , , , ,
MMR (MM/YY): ,
or Measles: ,
or Mumps: ,
or Rubella: ,
Heamophilus influenza B (MM/YY): , , ,
Hepatitis B (MM/YY): , ,
Vericella (chicken pox) (MM/YY): ,
TB Mantoux Test
Date of last test: Result: Positive Negative
Please provide any additional information about the participant’s behavior and physical, emotional, or mental health about which the camp should be aware:
Name of family physician: Phone
All persons who use facilities such as Nassau Racquet & Tennis Club for purposes of exercise, athletics, health and related activities, assume the risk of injury and property damage.
I recognize and acknowledge that there are certain risks of physical injury inherent in the named minor's participation in this program. He/she understands that he/she must obey all rules and regulations, follow all safety procedures and obey any and all instructors, assistant instructors and staff members assigned to the program. My child and I understand the risks associated with this program and my child and I have agreed to accept our responsibility in making this program a safe one.
I certify that the minor is in proper physical condition for safe participation in the Nassau Racquet & Tennis Club Junior Tennis Camp, including swimming activities, and I agree that it is incumbent upon me to immediately inform the Nassau Racquet & Tennis Club should the minor's physical condition change at any time prior to or during his/her participation in the program.
I expressly agree that this agreement is intended to be as broad and inclusive as permitted by the Laws of the State of New Jersey, and that if any portion of the agreement is held invalid, it is agreed that the balance shall continue in full legal force and effect and be valid.
In Consideration of the Nassau Racquet & Tennis Club permitting the named minor to participate in the Junior Tennis Camp, including swimming activities, I(we) the undersigned parent(s) or legal guardian(s) hereby waive and relinquish all claims I (we) may have as a result of said minor participating in the program against the Nassau Racquet & Tennis Club, its officers, agents, servants and employees. We further release and discharge the Nassau Racquet & Tennis Club, its officers, agents, servants and employees from any and all claims for injuries including death, damage or loss to property which may accrue to us on account of the minor's participation in said program and we further agree to hold harmless and defend the Nassau Racquet & Tennis Club, its officers, agents, servants and employees from any and all such claims.
Finally, I understand there is no provision for medication administration at Camp.
Signature Parent/Legal Guardian: Date:
Above named Parent or Guardian agrees to the Liability Waiver with this electronic signature.
Serving New Jersey including Princeton, Hillsborough, Bridgewater, Montgomery (Belle Mead & Skillman), Hopewell and the Surrounding Areas.
Nassau Tennis Club, 1800 Route 206, Skillman, NJ 08558 | 908-359-8730
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