Microsoft word - medical form camper 2011.doc

To be Completed by the Parent or Guardian This form be completed on both sides, signed and returned to the camp office by Please attach separate letter for conditions requiring detailed information   CAMPER NAME _______________________________________________ Camper’s Name: _________________________________________________________________ Date of Birth __________________ Age ______ Sex______ Height______ Weight_______ Parents/Guardian: Mother_________________________ Father___________________________ Home Address___________________________________________________________________ Home Phone___________________ Business___________________ Summer_______________ Cell Phone/Pager (Mother)___________________ Cell Phone/Pager(Father)_________________ Emergency Contact Other Than Parent________________________ Phone_________________ Camper’s Doctor Name/Phone Number:________________________Phone_________________ Current Red Cross/Royal Life Swim Level_____________________________________________ Ontario Residents: Please ensure your Health Card Number is accurate and complete   Health Card Number:__________________________________________ Version No.______ Non-Ontario residents: Insurance name and policy number: _____________________________________________________________________________ Health History: Check of the camper has had any of the following: Other________________________________________________________________________ Immunization Up to Date for: Diphtheria, Tetanus, Polio, Measles, Mumps, Rubella If not certain, please consult your pediatrician Allergies: Please list all allergies (attach separate page if necessary) Penicillin: _________________________________ Other________________________________ Bees / Insects__________________________ Animals______________________________ Food Allergies________________________________________________________________ Any Drugs, Medications, Injections to be Administered at Camp : These must be brought To camp or to the buses with instructions in ORIGINAL PACKAGING. Use extra page if needed: _______________________________________________________________________________ _______________________________________________________________________________ Can any of these medications be administered by the camper (e.g. Ventolin Puffer) _______________________________________________________________________________ Any Activity Restrictions? Please Explain: Attach additional page(s) if required _____________________________________________________________________________________ Any Diet Restrictions? _____________________________________________________________________________________ _____________________________________________________________________________________ Any Behavioral or Medical information which may be helpful to our Medical Staff (e.g. conditions, psychological counselling, etc.)? Attach additional page(s) if required _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Statement of Complete Disclosure and Transfer of Medical Authority: To the best of my knowledge, my child is in good health and has not been exposed to any infectious disease in the past four weeks. If he or she becomes exposed to any infectious disease between now and the time of departure for camp, I understand the Camp must be notified. I understand that my child may be placed on antibiotic or other types of medication for the routine treatment of infections and/or medical conditions without my notification. In the event of a medical emergency and/or special medical treatment, parents will be notified immediately. If we are not immediately available for consultation, I give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for and to order injections, anesthesia, surgery or any emergency medical procedure that is deemed necessary by the attending physician for my child, as named above. I give permission to the Camp to contact the camper’s family physician during the summer should medical advise be required. In signing this form, I have undertaken to fully disclosed any medical information/treatment and history required to ensure proper medical care of this camper. Print Name of Parent or Guardian:__________________________________________________________ Signature of Parent or Guardian_____________________________________ Date__________________ ******PLEASE NOTE: ORIGINAL FORM REQUIRED – PLEASE DO NOT FAX****** Date Complaint Diagnosis Treatment _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Source: http://www.campnewmoon.ca/wp/wp-content/uploads/2012/01/medical-form-camper.pdf