HEALTH AND RELEASE FORMS
          (Child will not be permitted to participate in the camp without these forms.)

CAMP______________________________LOCATION________________________________
NAME_______________________________________M/F_____AGE_____WT______HT____
ADDRESS________________________________________PHONE______________________

GENERAL HEALTH AND HISTORY

If the Junior should be restricted from any kind of activity, please note:________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
Please identify any medication history or condition, which would require special attention:____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
If the Junior will be taking any medication during the golf camp, please indicate dosage and the
name of the drug:_______________________________________________________________________

Has the Junior had (please circle) Measles, German Measles, High Blood Pressure, Asthma,
Diabetes, Chicken Pox, Pneumonia, Mumps.

IMMUNIZATIONS   ALLERGIES  DRUG REACTIONS
(include the dates)   (Yes/No)  (Yes/No)
Polio Vaccine_____________  Hay Fever_________ Penicillin__________________
Measles__________________  Eczema__________ Sulpha___________________
Tetanus Toxoid____________  Insect Stings_______ Antibiotics (type)___________
Mumps___________________  Asthma___________
Rubella___________________  Other (type)________ Other_____________________
Tuberculin Test_____________  _________________ _________________________

Physician's Name________________________________________________________________
Address__________________________________City_________________State______________
Physician's Phone Number_______________________________________________________

I hereby certify the named Junior is physically able to participate in the Palm Royale/Indio Junior
Golf Camp and that I know of no restrictions, physical impairments or any other facts which in any
manner limit his/her participation in such a program.

Parent or Guard Signature______________________________________Date_____________

INSURANCE INFORMATION

Carrier Name__________________________________Policy Number_____________________

Policy Holder Name_____________________________Policy Holder DOB__________________

I, the parent of_________________________________, give permission for my child to receive
emergency medical or surgical treatment and hospitalization if necessary.  I understand that every
attempt will be made to contact me, or the named person below, before taking this action.  I hereby
waive and release the Staff, Camp Management and Sponsors from any injury or illness incurred
while at Camp.  I UNDERSTAND THAT THERE IS A RISK OF INJURY TO MY CHILD AS A
RESULT OF CAMP ACTIVITIES, AND KNOWINGLY AND VOLUNTARILY ASSUME ALL RISK
OF SUCH INJURY.  I will be financially responsible for any medical attention needed during camp
or resulting from an injury received at camp.  My medical insurance shall be the primary medical
insurance coverage for any medical treatment.

Parent or Guardian Signature_____________________________________Date______________

Home Phone_____________________________Work Number___________________________

Phone Number while my child is at camp (if different from above)_________________________

Person to contact in the event I cannot be reached_____________________________________

Phone Number of contact_________________________________________________________
I understand Palm Royale/Indio and the Eaglelinks Golf Company retains the right to use for publicity
and advertising purposes, photographs of juniors taken at the camp.

Signature__________________________________________________Date_______________