Camp Manual Brown University

Camp at Brown University
Insurance Waiver – Medical Form
All Summer Athletic Camps at Brown require that each participant provide proof of
health insurance.
PLAYER INFORMATION: PLEASE PRINT
Name:______________________________________Social Security #:______________
Address:__________________________________________Date of Birth:___________
Home Phone: ( ______ ) _______________________
INSURANCE INFORMATION
PLEASE ATTACH A FRONT/BACK COPY OF YOUR INSURANCE CARD
Name of Insured: _____________________________ Place of Business: ____________
Relationship: ________________________________
Insurance Company: ____________________________________________________
Insurance Co. Mailing Address: ___________________________________________
Phone Number: ( ______ ) _________________________
Policy – Group #: _______________________________________________________
PARENT-GUARDIAN INFORMATION
Mother: _____________________________ Father: _____________________________
Address: ___________________________ Address: ____________________________
___________________________
____________________________
Home Phone: ( _____ ) _______________

( ______ ) ___________________

Work Phone: ( _____ ) _______________

( ______ ) ___________________

Cell Phone:

( ______ ) ___________________

( _____ ) _______________

Alternate person to call in case of an emergency:
Name: _____________________________________ Phone: ( ______ ) ____________

Continued on other side!