EXAMINATION FORM

Have your personal physician use this medical form or one like it to indicate the results of your physical examination. A team physical from the last school year is also satisfactory.
Before the first day of camp mail form to:
Don Lane
107 Raintree Ct
Nicholasville, Ky 40356

No one may participate in any camp activity without a medical form completed and signed by his/her physician and on file in Camp office.

I have examined and found him/her to be free of communicable disease and able to participate in the activities of basketball camping.

Camp Date ____________________

Session(s) #____________________

Hosp. Insurance Co.____________________

Policy #____________________

Any physical limitations____________________

Any physical impairments____________________

Allergies?____________________

Comments____________________

Date of exam____________________

Dr.'s Signature____________________