Medical Clearance Form 3
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MEDICAL CLEARANCE
I hereby certify the named camper is physically able to participate in Auburn University Sports Camp and
that I know of no physical impairments which would in any manner limit his/her participation in such
program. Physician’s Signature________________________________________Date______________

OR
Provide any physical accompanied with a physician’s signature dated within 12 months
of camp with registration or at check-in (State HS physical, etc)

MEDICAL & INSURANCE INFORMATION
Hospitalization Plan: Claim No._______________________ Company____________________________
City________________________State_________________

Zip Code____________________________
Phone______________________________

*FRONT AND BACK COPY OF INSURANCE CARD SHOULD BE INCLUDED AT TIME OF
CHECK-IN*

Medical History (if pertinent):
_____________________________________________________________________________________
Allergies, present medication, special considerations:
_____________________________