Camper’s Full Name ____________________________________ Home Phone _______________________
Mother’s Employer ___________________________________Mother’s Daytime Phone _________________
Father’s Employer ___________________________________Father’s Daytime Phone _________________
Health Insurance Company _________________________________________________________________
Name of Primary Holder ____________________________________________________________________
Policy Number ___________________________________________________________________________
Family Doctor ____________________________________________________________________________
Doctor’s Phone ___________________________________________________________________________
Allergies, if any ___________________________________________________________________________
If you will be bringing any medication other than aspirin with you to camp, please list medication and the
condition for which it is needed ______________________________________________________________
__________________________________________________________________________________________________
List any physical, mental or emotional health problems which require special provisions:
_______________________________________________________________________________________
Your signature on this form with authorize the University of Miami to proceed with under delay should a
situation occur which requires immediate medical attention. The University of Miami will attempt to contact one or both parents at the phone numbers listed above before any action is taken.

I(We) grant permission for my (our) child to receive treatment in the event of an emergency in which an injury or
illness occurs while he/she is attending Guitar, Bass Guitar and Drumset Camp at the University of Miami.

_______________________________________________________________________________________
Parent or Guardian Signature Date

_______________________________________________________________________________________
Parent or Guardian Signature Date

IMPORTANT!!!! ALL CAMPERS!
PLEASE READ THIS MEDICAL FORM, SIGN AND FAX ALONG WITH THE “REGISTRATION FORM” AND THE "RELEASE FORM"
BEFORE JUNE 1, 2012.