Whitman Hanson Soccer
Home of the Panthers!
www.whathletics.com

A Summer of Fun for our Future Panthers

The school nurse may not be present during before, after school, or extra curricular programs

Camper Information

First Name *

Last Name *

Grade as of September 2024 *

Age at Camp Time *

Date of Birth *

T Shirt Size *

Please Select Which Camp You Are Signing Up For *

Parent/Guardian Information

Parent/Guardian Name *

Address 2

Town *

State

Zip

Email Address *

An email confirmation will be sent upon receipt of your registration form.

Phone

Allergies *

My child has the following medical condition that may require immediate attention (911) at school sponsored or activities practices/events that occur outside of the regular day: *

BASIC ACTION PLAN TO FOLLOW - UNLESS PARENT PROVIDED INDIVIDUAL ACTION PLAN: Allergic Reaction: Symptoms include - Difficulty breathing, shortness of breath, wheezing, difficulty swallowing, hives, itching, swelling of any body part, and vomiting. ACTION - CALL 911 AND ASSIST THE STUDENT IN USING AN EPINEPHRINE AUTOINJECTOR IF PRESCRIBED AND AVAILABLE Asthma: Symptoms include - Difficulty breathing, wheezing, and shortness of breath. ACTION - IF THE STUDENT HAS THEIR INHALER, ALLOW THEM TO USE IT. IF NO RELIEF OF SYMPTOMS IN 5 MINUTES CALL 911. IF NO INHALER IS AVAILABLE, CALL 911 IMMEDIATELY. Diabetes: Symptoms of Low Blood Sugar include - Hunger, sweaty, pale, feels shaky, and headache ACTION - ALLOW STUDENT TO DRINK JUICE, EAT GLUCOSE TABS OR FAST ACTING CARBOHYDRATE FROM THEIR EMERGENCY PACK. HAVE STUDENT TEST THEIR BLOOD GLUCOSE LEVEL AND RECORD THE NUMBER. IF NO CHANGE IN SYMPTOMS IN FIVE MINUTES CALL 911 AND HAVE THE STUDENT REPEAT ALL OF THE ABOVE. Seizure: Altered consciousness, involuntary muscle stiffness or movements, drooling/foaming from the mouth, temporary halt in breathing, loss of bladder control. ACTION - GUIDE STUDENT TO THE FLOOR TO PROTECT FROM FALLING, AND CALL 911. NEVER PUT ANYTHING INTO THE STUDENT’S MOUTH. Parent/Guardian child-specific instruction for any of the above action plans - include the location of emergency medication: *

Does your child require Epinephrine? *

Does your child require an inhaler? (if yes, please make sure your child's name is on it) *

Insurance Type & Number *

I give permission for my son/daughter to participate in the WH Soccer Camp. I agree to hold Whitman-Hanson, David Floeck, all coaches, camp counselors, officials, trainers and agents free from any liability whatsoever in the event of any type of injury or contraction of Covid 19; I also certify that my son/daughter has been through a physical examination within the last 13 months and that he/she is healthy and able to participate in the camp. I also give my permission for the program to seek medical attention for my son/daughter in the event of an injury, but again will not hold the camp, its coaches, Whitman-Hanson Regional School District or its agents liable for said medical care or lack there of.

I am aware that attending this program could put family members at risk in terms of the transmission of Covid 19. I affirm that I understand these risks and will not hold Whitman-Hanson Regional School District, its employees, its agents or any other party liable for any issues that may arise as a result of attending this program. The school nurse may not be present during before, after school, or extra curricular programs

Date *

Parent/Guardian Signature (by typing my name I agree that this will represent a valid electronic signature)

Please mail a signed copy of this form with a copy of a recent Physical Exam with your payment.

Payment Information

Send checks to ("Panther Soccer Camp" Whitman-Hanson Regional High School, 600 Franklin Street, Whitman, MA 02382; Please send full payment of $225 with your registration for each week of camp. Please make checks payable to Panther Soccer Camp.