Taylor Basketball Health Statement
(To be filled out by physician)

Taylor University                             Social Security #_________________
Upland, Indiana                              Date of Birth _____________________

Name of Camper                                                             Date                     
Age      Address                                         City                   State    Zip        Guardian’s Name                                                   Occupation                     Phone Number                            Emergency Phone Number______________

Previous Injuries: (list)                                                                                                                    
Allergic Reactions:                                                                                                                        
Medication Needed:                                                                                                                       
Date of Last Tetanus:                   Other Instructions:                                                                  
Medicine brought along to camp:                                                                                                  
Camper may use Tylenol: [  ] yes [  ] no
Signature of Physician                                                                                 

I authorize the medical staff at Taylor University, or others to whom my son/daughter is referred, to provide appropriate diagnostic and/or medical care during the camp week. I am to be contacted prior to further diagnostic, surgical, or specialist care.
Parent’s or Guardian’s Signature