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METROROCK NORTH

40 Parker St.
Newburyport, MA 01950
978.499.7625 

I hereby grant MetroRock and its agent’s full authority to take whatever action they deem necessary regarding my child’s health in the case of an emergency where I am unable to make a timely decision. I fully release MetroRock and its agent’s from any liability in connection with those decisions. I grant permission for emergency treatment by a private physician and/or hospital or emergency health care facility staff, under the same circumstances as above, if needed. Any such action will be taken in my best interest. 


Today's Date: October 26, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

HEALTH HISTORY AND EMERGENCY TREATMENT AUTHORIZATION


Insurance Company:

Medical Insurance Policy No.:

Name of Insured:

Primary Care Doctor:

In case of emergency while I’m at MetroRock Climbing Camp, please contact: 


Name:

Phone:

Address:

City:

State:

Zip:

Relationship to participant:

Alternative Contact:

Phone:

Participant Medical Information: 

(Does/Has) your child: 

Had a broken bone *
No
Yes

Please explain if answer is “yes”:
Have diabetes*
No
Yes

Please explain if answer is “yes”:
Have asthma Suffer from seizures: *
No
Yes

Date of Last:
Been diagnosed with a heart murmur *
No
Yes

Please explain if answer is “yes”:
Suffered from joint pain/injury*
No
Yes

Please explain if answer is “yes”:
Been dizzy during or after exercise *
No
Yes

Please explain if answer is “yes”:
Had emotional difficulties for which professional help was sought *
No
Yes

Please explain if answer is “yes”:
Had back problems*
No
Yes

Please explain if answer is “yes”:
Felt chest pain during exercise *
No
Yes

Please explain if answer is “yes”:
Wear glasses or contacts*
No
Yes

Please explain if answer is “yes”:
Ever been knocked unconscious*
No
Yes

Please explain if answer is “yes”:
Ever been hospitalized *
No
Yes

Please explain if answer is “yes”:
Ever had surgery*
No
Yes

Please explain if answer is “yes”:
Is your child currently taking any medications (prescribed or otherwise): *
No
Yes

Please explain if answer is “yes”:
Does your child have any known allergies or dietary restrictions: (food, medications, bees, insects, other): *
No
Yes

Please explain if answer is “yes”:

Please describe any current conditions that require medication, treatment, or special restrictions or considerations while at camp:

CAMPER IMMUNIZATION RECORDS ARE REQUIRED TO ATTEND CAMP. 

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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