Fillable Please Complete One Registration Form Per Child (Page 2 of 3) in pdf

Please Complete One Registration Form Per Child Page 2

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Child’s Medical Information Form:

(Please completed and return with your registration form)

Basic Information:

First Name:

Last Name:

Ontario Health Card #:

Exact Name on Card:

Date of Birth: month/

day /year

Name of Family Doctor:

Telephone:

Ext:

Emergency Contacts:

(Someone other than a parent and/or guardian currently listed on registration form)

1. Emergency Contact*:

Relationship to Child:

Phone:

2. Emergency Contact*:

Relationship to Child:

Phone:

*These people know my child and have agreed to be contacted in the event I am not available.

Medical Information:

All medication, vitamins etc. must be turned over to the Wellness Coordinator at registration. They should be brought to camp in the original

container, appropriately labelled for each camper.

Please indicated in the space provided any special medical conditions, or health and wellness issues we should be aware of:

Allergies:

Reactions:

Dietary Restrictions:

Medication

(taken regularly)

Dosage:

Time(s):

Yes

EPI Pen

Inhaler

Has your child been immunized?

Please indicate if camper will bring his or her own:

Other Relevant Information:

Please describe other relevant medical information including health conditions not treated with medication, recent operations, illness or injuries this

camper has had and give details:

Health Declaration and Emergency Authorization:

To the best of my knowledge, this camper is in good health, does not have a communicable disease and is able to participate in all aspects of the camp program. If he/she becomes

exposed to any infectious disease four weeks prior to camp, I understand that the Camp Director must be notified in writing. I give permission for the medical information provided to be

shared with the appropriate camp staff and outside medical personnel as necessary.

Authorization for Emergency Medical Treatment:

In case of an emergency and we are not immediately available for consultation, I hereby give permission to the physician selected by the Camp Director, to hospitalize, secure proper treatment for and

order injections, anesthesia or surgery for my child, as named above with the cost of necessary prescriptions and medical expenses to be borne by me.

Name of Parent/Guardian (please type):

Date:

month

day

year