Camper Health Form 2017

Parents/guardian complete both pages and sign

Camper Name: ______Age: ____ Birth date: ____/____/____

DD MM YY

Home Address: ______

City: ______Postal Code: ______

Provincial Health Insurance Number: ______

Other Health Insurance: ______

(Parent or Guardian is responsible to have insurance covering the camper)

Family Doctor: ______Telephone: ( ) ______

The Camper Lives With:

Parents Foster Parents Mother Father Guardian Grandparents

Name of Parent(s) or Legal Guardian(s): ______

Emergency Contact Info:

IN CASE OF ILLNESS NOTIFY: ______

Relationship: ______

Telephone: ( ) ______Alternative Telephone ( ) ______

IF UNAVAILABLE NOTIFY: ______Relationship: ______

Address: ______Telephone: ( ) ______

Medication Required At Camp:

All medications must be in the custody of the Camp nurse. All medications will be administered by the Camp nurse. Please write instruction on how to administer medication below.

Medical Information and History

1. Does the camper have or suffer from any of the following:

Heart Trouble Bedwetting Sore Throat Fainting Asthma Nightmares

Upset Stomach Headaches Diabetes Sleep Walking Ear Aches

Poison Oak/Ivy Convulsions Past Surgery or Surgical Procedures Serious Injury

None of theabove.

Provide detailed information in the comment section below:

2. Does the camper have any physical, mental or emotional weakness or disability, chronic condition or

recentillness which the staff should be aware of that may require attention? Please describe fully and

use aseparate page if necessary.

3. Has the camper had any recent exposure to contagious disease? Yes No

4. Does the camper have any allergies? Yes No

If so, please list below and give the type and severity of the reaction as well as the treatment given.

Allergy______

Reaction______

Treatment ______

5. Are all the camper’s immunizations up-to-date? Yes No

6. Does the camper wear prescription glasses or contact lenses? Yes No

7. Does the camper have any restrictions on swimming or other camp activities?

Yes No

Provide details for restrictions on swimming and /or camp activities:

CONSENT

I hereby authorize the camp nurse and/or camp director to secure such medical advice and services as may bedeemed necessary for the health and safety of my child.

Parent/Guardian Signature: ______

Date: ______