Michigan State University Spartan Athletics

Medical Information


Participants are automatically enrolled in MSUs camp insurance plan. Eligible expenses will be paid only if they are in excess of other valid and collectible insurance.



List any medical conditions that camp personnel should be aware of:
(Use as much space as necessary)


List any medications currently taking:
(Use as much space as necessary)



Please check this box if you DO NOT want your child to receive over the counter medications.


Allergies/Drug Reactions:
Hay FeverYes No   SulphaYes No
AsthmaYes No   PenicillinYes No
EczemaYes No   Antibiotics (list below) Yes No
Insect StingsYes No   AspirinYes No
NutsYes No

Other/Additional Information:



Emergency Contact Information

*Required
Name:
Daytime Telephone:
Nighttime Telephone:
Cell Phone:


Insurance Information

Name of Medical Insurance Provider:Insurance Telephone:
Name of Insurance Policy Holder:Policy Holder Date of Birth: (MM/DD/YYYY)
Insurance Policy Number:Insurance Group Number: (if applicable)


Authorized Pick Up Contact Information

Contact 1
Name:
Telephone:



Parent or Guardian


You must enter your name into the two fields below and then click the two buttons labelled "Do." This constitutes authorization, certification, and acceptance of these two statements.

*We cannot process your application if you fail to do this.


I, , as parent or legal guardian of the participant named above,

Do     Do Not


authorize MSU to seek medical and/or surgical treatment which is reasonably necessary to care for the participant. I further authorize the medical facility that treats the participant to release all information needed to complete insurance claims. I acknowledge my responsibility to pay all costs associated with the participant's medical care and authorize all insurance payments, if any, to be made directly to the medical facility.
I,

Do     Do Not


certify that I am over the age of 18 and parent or legal guardian of participant named above, and I acknowledge that I understand and agree to the terms as outlined above.



IN ACCORDANCE WITH NCAA RULES, MICHIGAN STATE SPORT CAMPS ARE OPEN TO ANY AND ALL THAT WOULD LIKE TO ATTEND, LIMITED ONLY BY ATTENDANCE, AGE, NUMBER AND GRADE LEVEL. HOWEVER, CAMP ATTENDANCE AT MICHIGAN STATE SPORT CAMPS (INCLUDING ATTENDANCE AT ELITE OR ADVANCED CAMPS) IS NEVER RESTRICTED BY A CAMPER'S SKILL LEVEL OR COMPETITIVE EXPERIENCE.