Form B: Medical Disclosure Form (Child) - Parks, Recreation And Culture Department printable pdf download

Form B: Medical Disclosure Form (Child) - Parks, Recreation And Culture Department

CITY OF SURREY

PARKS, RECREATION AND CULTURE DEPARTMENT

B: MEDICAL DISCLOSURE FORM (CHILD)

Please PRINT all information and fill out completely

Personal information contained on this form is required for the operation of the Program and is collected under

Section 26(c) of the Freedom of Information and Protection of Privacy Act. The information is kept confidential.

This form must be completed and submitted in order for your child to participate.

A. PERSONAL INFORMATION:

Participant’s Name:

Program Name:

Activity:

Course No.

Start Date:

End Date:

Telephone:

Birth Date:

Name of Parent/Guardian:

In case of emergency, please contact:

Parent/Guardian/Other

Other Contact

Name and Relationship

_______________________________

_____________________________

____________________________

_______________________________

_____________________________

____________________________

Home Phone ___________________

Home Phone _________________

Emergency Phone _______________

Emergency Phone _____________

B. MEDICAL INFORMATION:

Doctor's Name:

Phone No:

Care Card No:

Dependent No:

(Please explain answers fully)

Does the participant have any medical conditions or take any medications that we should know about?

(e.g. asthma) If yes, you must complete an "Administration of Prescribed Medication" form.

Circle one:

YES

Form B: Medical Disclosure Form (Child) - Parks, Recreation And Culture Department