This medical and insurance information must be completed to allow your son’s participation in the
basketball camp. Please fill out and bring it to camp when you check-in.


Campers’ Name______________________________________Home Phone__________________

Parent/Guardian Phone #________________________Emergency Phone#___________________

Your son will be spending (3) days on the campus of DePauw University for the Super Hoops
basketball team camp. We are asking you to authorize treatment of minor injuries for
medical problems which may be advised or recommended for your son by the attending DePauw trainers.
In event of a serious injury or illness, we will proceed before contacting you only if the situation
is urgent and does not permit delay.

I indemnify and hold harmless Super Hoops and staff, DePauw University and staff and DePauw trainer
as well as its representatives from all claims for personal illness or injury that my son may sustain
while traveling to or from, or during his attendance at the Super Hoops team camp. I hereby give
my consent for my son to be treated for injuries and medical problems.


PARENTS/ GUARDIAN’S SIGNATURE_____________________________________DATE_________


Campers must be covered by insurance. Please list your insurance information:

Name of Insurance company___________________________________________

Policy holder’s name_____________________________Relationship to camper________________

Please note below any special medical considerations concerning your son’s current
medications allergic reactions, injuries, etc..
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

This form must be turned in at check-in to allow your son to participate in the Super Hoops camp.