Microsoft word - health form - 2014

2014 Camper Health Form
IMPORTANT: Health Form must be submitted to camp office by April 30th or upon registration if after that date
Please ensure it is filled out completely and accurately. Campers cannot attend camp without a current health form on file prior to camp. CAMPER INFORMATION: (print clearly)
Submit completed health form by email or mail, do not fax.
Last Name:
PARENTS / GUARDIANS & EMERGENCY CONTACTS: (print clearly)
(attach separate sheet of paper if necessary)
Martial Status of camper's parents/guardians: Single Married Separated Divorced Widowed Common Law Other:
Legal Custody: who has Custody and is Legally Responsible for this camper (be sure to include their contact information below):
Both Parents (live together) Joint Custody (live apart) Mother Father Grandparents Guardian Foster Parents Other: List in order who should be contacted in case of emergency – be sure to include parents/guardians:
1st Contact: Mr. Mrs. Ms. Miss Dr.
2nd Contact: Mr. Mrs. Ms. Miss Dr.
3rd Contact: Mr. Mrs. Ms. Miss Dr.
Camper’s Health Card #:
Out-of-Canada campers: indicate any medical plan, numbers & billing address, (attach separate piece of paper if necessary) Family Doctor:
Permission for our Camp Nurse/Doctor to contact your Family Doctor if necessary? Yes No
Immunization Dates: Tetanus:
Pertussis:
1. DIETARY RESTRICTIONS: Vegetarian Vegan Lactose Intolerant Gluten Free Other:
2. ALLERGIES: Be specific, attach separate page if necessary. If camper uses an Epipen, they must bring it to camp.
**If your child has a life-threatening allergy you MUST fill out an “ANAPHYLAXIS EMERGENCY PLAN FORM” in addition
to this health form. Forms available on our website: www.campkawartha.ca/summer-camp/
Please note, we do NOT use or allow foods/snacks that contain nuts or traces of nuts.
Management / Treatment / Medication Last Reaction 3. ASTHMA: Does your child suffer from asthma? No Yes If yes, indicate severity? Mild Moderate Severe
What are the triggers for these attacks? 4. MEDICATIONS:
Is camper currently on any medication (prescription or homeopathic)? If so, what? How and when is this medication administered? Main Office: Camp Kawartha, 1010 Birchview Road, Douro-Dummer, ON K0L 2H0 www.campkawartha.ca [email protected] 2014 Camper Health Form (continued)
Last Name:
First Name:
MEDICATIONS:
*** All prescription and over-the-counter medications must be left with the health care staff while at camp ***.
Prescription medications must be in their original container or pharmacy issued blister packs and must be labeled with the
doctor’s name, child’s name, dosage, schedule, route and date. Over the counter medications must be in the original container
with proper labeling.
5. OVER-THE-COUNTER MEDICINE:
Check (
) if you approve the use of the following over-the-counter medicine that the camp has, for your child, if deemed necessary Gravol Benadryl (antihistamines)
If NO, what would be an appropriate alternative? 6. ACTIVITIES: Camp Kawartha is located on a rugged, wooded site. Most of the activities take place outdoors. All 2-week, 3-
week, tripping and leadership programs go offsite for an overnight camping/canoe trip.
Does your child have any physical, health, developmental, behavioral, or emotional condition that may affect his/her ability to
participate in camp activities?
*** Parents will be responsible for any charges/expenses incurred to Camp Kawartha if their child needs to be evacuated from
an off-site trip, due to a medical or health condition, that was not disclosed prior to their child’s attendance.
7. HEALTH HISTORY: Check ( ) if camper has had, or double-check (
) if camper currently has any of the following:
If your child has or had any of the above, please give details. Does it affect their ability to participate in activities? If so, how? 8. RECENT hospitalization, operation, injury, serious illness, or infectious disease: If so, give date and details:

9. FEMALE CAMPERS: Has this girl menstruated? Yes No If not, has she been told about menstruation? Yes No

10. OTHER: please detail any other medical information of use to the Camp Physician or Camp Nurse:

IMPORTANT REMINDERS - please read carefully!

To the best of my knowledge, my child is in good health. I will notify the camp if there is any change in my child’s health,
or he/she is exposed to any communicable disease within 3 weeks prior to arrival at camp.
In the case of medical emergency, I understand every effort will be made to contact parents or guardians. In the event I
cannot be reached, I hereby give permission to the physician/nurse selected by the Camp Director to hospitalize, secure
proper treatment, order injection, anesthesia or surgery for my child as named above.
I agree to reimburse the camp for any prescriptions or medical expenses incurred for this camper.
I will submit any changes to this health form in writing to the camp prior to arrival.
I will do a head lice check on my child regularly and within 3 days before arriving at camp. Campers found to have head lice
on arrival will not be allowed to enter camp until the matter has been resolved. There will be no refund of camp fees.
Signature of Parent/Guardian:
Main Office: Camp Kawartha, 1010 Birchview Road, Douro-Dummer, ON K0L 2H0 www.campkawartha.ca [email protected]

Source: http://www.campkawartha.ca/pdf/summer-camp/Health-Form.pdf